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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202851
Report Date: 10/18/2024
Date Signed: 10/18/2024 02:25:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220815150455
FACILITY NAME:PARADISE ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:WILEY, ERIN ROSEFACILITY TYPE:
740
ADDRESS:2177 17TH AVETELEPHONE:
(831) 475-1386
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:39CENSUS: 22DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Lusanta KaiyomTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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 Resident was left in soiled clothing for extended period of time.
Staff are not providing resident with assistance for activities of daily living.
Facility did not safe guard residents personal belongings
Facility is not providing recreational activities for residents
INVESTIGATION FINDINGS:
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On 10/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensee, Lusanta Kaiyom and explained the purpose of today's visit.

Regarding the allegations of resident was left in soiled clothing for extended period of time and Staff are not providing resident with assistance for activities of daily living. RP stated that R1 is incontinent, and the staff did not provide incontinence service and left R1 in his/her feces for several hours in the room. RP stated the facility did not provide a shower for R1 for the first 7 days. RP also stated that the facility staff are only giving R1 showers once per week instead for 2-3 times per week.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20220815150455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PARADISE ASSISTED CARE CORP
FACILITY NUMBER: 445202851
VISIT DATE: 10/18/2024
NARRATIVE
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LPA was able to interview staff members (S1 & S2). Both mentioned that there's always 3 caregivers and 1 manager. S1 added that there are 3 staff per shift, NOC shift is 2, evening is 3 caregivers and a med tech. S2 mentioned that there might be a delay on help when everyone is like lunch time. S2 also added that Some residents are aggressive sometimes, so they wait and give them time if they refuse showers. S3 also mentioned that some residents refuse showers, so they dress them up with clean clothes and still try to ask if they want to shower after. AD1 also mentioned that they talk to the family and the resident as to how many times and what time the showers will be scheduled. If a resident refuses on the scheduled time, then they ask again 3 time within the day. If the answer is still no, then the shower will be scheduled the next day.

Regarding the allegation of facility did not safeguard residents’ personal belongings, RP stated that someone stole R1s big package of diapers that RP had purchased and placed in R1s room.

LPA observed the facility to have their own supply of diapers in case a resident runs out. AD1 stated that they use these supplies to also cover the residents who runs out of supply because sometimes families forget to order. AD1 doesn’t remember an incident where a family member complained of diapers being lost.

Regarding the allegation of Facility is not providing recreational activities for residents, RP stated that the facility provides no recreational activities for the residents at the facility.

During the interviews, S1 mentioned that there is bingo, exercises and a guy who plays piano every Wednesday. There's also a one-man band that comes every Monday. Residents are brought down for the activities. We don’t force residents to join, sometimes they just watch tv in their room. AD1 also added that they have memory games, puzzles, word search and coloring books, some activities for memory care. When residents refuse to join, we ask them at least 3 times.

Based on interviews, observations and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
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