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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 02:39:58 PM

Substantiated


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
03/24/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230324170427
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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Facility staff have not received required training hours prior to assisting with medications
Unqualified staff assisting with medications
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 facility staff have not received required training hours prior to assisting with medications, and unqualified staff assisting with medications. Reporting party (RP) stated that neither the "med techs" or caregivers have the 24 hours of training, 16 hours hands on, 8 hours instruction and followed by passing an examination testing the employee's comprehension and competency.

RP also shared that there is a med tech (MT) on staff during the time of 7-3, the owner was unable to provide evidence if MT had passed the medication test. The owner stated that the MT had been a med tech at the facility earlier and assumed this was done but had not verified it.

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Substantiated
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 7
Control Number 26-AS-20230324170427
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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Based on records review, Licensee was able to provide proof of training from Relias for MT. 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.

However, during the interviews of staff members (S2, S3, S4), it was found out that 3 out of 3 didn’t have a documented training with regards to medication.

Therefore, based on interviews and records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed and a copy of this report and appeals rights 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)
Page: 2 of 7
Control Number 26-AS-20230324170427
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2024
Section Cited
CCR
87411(c)(3)(D)
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87411 Personnel Requirements-General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as ...(3) The training shall include, but not be limited to, the following: (D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4)...
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Licensee to submit a plan to address staff training. Licensee to submit by POC due date.
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This was not met as evidenced by:
Based on records review, 3 out of 3 staff members don’t have documented training with regards to medication, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
03/24/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230324170427

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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Resident medical records are inaccurate
Facility does not store Narcotics appropriately
Medications are not properly stored
Facility staff spoke to resident inappropriately
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 medical records are inaccurate, facility does not store Narcotics appropriately and medications are not properly stored, RP stated that There is no accountability for narcotics. No one counts and verifies or documents the narcotic counts at all. If someone gives a narcotic, there is minimal documentation. There are extra narcotics left in an envelope in an unlocked cabinet for the after-hour care giver to administer if needed. There have been no audits by the administrator to verify if the narcotic log is correct. No one is documenting on the narcotic log. There is no way to tell if narcotics have been taken out of the med room. There is no accountability, no documentation. On multiple occasions, RP found loose medication on the floor of the med room, and freely scattered in the top drawer of the medication cart, not labeled.

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: 4 of 7
Control Number 26-AS-20230324170427
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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During RPs interview with LPA Heberle, with regards to loose medication on the floor, it was stated that LPA asked RP if there is any evidence or photographic proof. RP stated that there is none.

LPA interviewed AD1 and LPA asked for a walkthrough on how the medication pass is done. A staff member S5 walked the LPA through the process for medication. It was explained by S5 that when new medications come in, they log it in the centrally stored medication and destruction records (CSMDR). They then put in in different plastic storages that are assigned to each resident. Labeled with room number also. All medications are locked in the medication room where only staff have access too.

LPA observed the medication room to be always locked, there is also a medication cart that has PRN and Narcotics stored with different keys being used. There are also 2 cabinets where routine medications for residents and overflow are stored which also has separate locks.

Regarding the allegations of facility staff spoke to resident inappropriately, RP stated that a staff (S1), called a resident "Boo" Totally disrespectful. S1 had no clue that was not appropriate.

LPA Heberle interviewed 3 staff members. S2 stated that they only seen staff members referred to residents by name, never pet names. S3 mentioned that they have not heard any staff members speak to residents inappropriately. Staff members don't use pet names, they always address by name.

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.
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: 5 of 7
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
03/24/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230324170427

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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Facility caregivers are not receiving required training hours
Facility staff have not been providing training on emergency preparedness
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 caregivers are not receiving required training hours, RP stated that the required basic (not medication administration) 40 hours initial training and 20 hours each year for the caregivers is not being done.

Based on records reviews, facility provided a record of training from Relias. The records showed the required training received by caregivers/staff in the facility.

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: 6 of 7
Control Number 26-AS-20230324170427
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 have not been providing training on emergency preparedness, RP stated that they are not sure that the requirement that "All employees must be trained upon hire and annually on the community's emergency preparedness plan and that all employees must participate in a quarterly emergency preparedness drill is happening. The owner said only 2 employees have to do this.

Based on records review, there is a log of training for emergency preparedness dating back 12/21/2021, 3/8/2022, 7/28/2022, 10/10/2022, 12/20/2022, 3/4/2023, 6/20/2023, 9/9/2023 & 12/20/2023. All are signed by staff members present during training and topics covered are fire and earthquake drills.

Based on interviews, 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.

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: 7 of 7