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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 02:30:10 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
03/16/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230316163646
FACILITY NAME:PARADISE ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:CHRISTINA RIVASFACILITY 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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9
Facility staff leave medications in residents' rooms.
Facility staff left resident on the floor for an extended period of time after falling.
Facility does not have adequate staffing.
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 allegation of Facility staff leave medications in residents' rooms, reporting party (RP) stated that Medications have been left in residents’ rooms.

LPA observed random rooms during several visits and there were no medications left in the rooms. All medications are locked in the medication room. There is a resident (R1) who is able to manage medications and has this medication in a locked box inside the room.

page 1 of 2
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 4
Control Number 26-AS-20230316163646
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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Regarding the allegation of Facility staff left resident on the floor for an extended period of time after falling, RP stated that a resident (R2) fell from the bed on either 3/4/2023-3/5/2023 during NOC shift and was left on the floor more than 1 hour.

Based on records review, an incident report was submitted by the Licensee. R1 was sent to hospital after it was found out that R1 had an unwitnessed fall. Licensee has already addressed the issue with the staff.
Regarding the allegation of facility does not have adequate staffing, RP stated that a staff member (S2) let RP know that they are always short staffed especially on the weekends.

LPA interviewed the Licensee (L1), and it was stated that for staffing, 3 in the morning, 3 in the afternoon, 3 NOC shift. If it is short staffed, the manger stops managerial work and steps in to help. L1 and L2 will also help, be on the floor, serve meals, clean up. When someone calls off, we have a list of people that are on call or not scheduled that we can ask to come in.

Based on interviews 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 allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.
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)
Page: 2 of 4
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
03/16/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230316163646

FACILITY NAME:PARADISE ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:CHRISTINA RIVASFACILITY 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):
1
2
3
4
5
6
7
8
9
Facility does not have a qualified administrator.
Facility staff are not adequately trained.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 allegation of facility does not have a qualified administrator, Reporting Party (RP) stated that since 2/2/2023 the facility hasn't had a qualified administrator.

Based on records review, the facility has a qualified administrator namely the Licensee. Administrator Certificate provided has qualification date of 8/9/2021 to 8/8/2023.

Regarding the allegation of facility staff are not adequately trained, RP stated that S1 is the med tech at the facility does not have a med tech certification.

page 1 of 2
Unfounded
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: 3 of 4
Control Number 26-AS-20230316163646
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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5
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Based on records review, Licensee was able to provide proof of training from Relias for S1. The following topics were used for Medication training: Actions and Interactions of Common Medications; Assisting with Self-Administration of Medications: Guideline, Medication Orders, Procedure, The Basics; Medication Documentation for California; Providing Medication Assistance – California, Psychotropic Medications: Antipsychotics and Beyond. All trainings were finished through online completion on 2/5/2022.

Based on interviews and records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

page 2 of 2
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)
Page: 4 of 4