445202851-11-7-2025-26-AS-CKAI-DPP2D4-20251224161743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202851
Report Date: 11/07/2025
Date Signed: 11/07/2025 03:45:01 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
08/20/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250820110316

FACILITY NAME:	PARADISE ASSISTED CARE CORP		FACILITY NUMBER:	445202851
ADMINISTRATOR:	CHRISTINA RIVAS		FACILITY TYPE:	740
ADDRESS:	2177 17TH AVE		TELEPHONE:	(831) 475-1386
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	39	CENSUS: 24	DATE:	11/07/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrators Saaj and Lusanta Kaiyom		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Licensee is not preventing resident's room from being infested by ants.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marcella Tarin conducted a complaint investigation visit to deliver the findings of the above allegation. LPA met with Administrators Saaj and Lusanta Kaiyom. LPA stated the purpose of the visit.

On 8/20/2025 the Department received a complaint about the above allegation.

On 8/21/2025 LPA Tarin conducted the initial 10-day complaint investigation visit and interviewed staff, residents and inspected random resident rooms.

On 8/20/2025, LPA Tarin interviewed Reporting Party (RP). RP states it was brought to his/her attention on 8/11/2025 that R1 had ants in his/her room and on his/her body.

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250820110316

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: 11/07/2025

NARRATIVE

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On 08/21/2025 LPA interviewed ADM. ADM stated it was brought to his/her attention by W1 that R1 had ants in his/her room and on his/her body on 8/11/2025. ADM stated ants come into the facility during the summer months. ADM stated he/she had purchased ant sprays to get rid of the ants inside the facility, but “the ants just keep coming.” ADM stated there were no work orders for pest control, instead bug sprays and pesticides (for outdoors) were being used on the ants. ADM stated he/she offered to move R1 into another room, but there were ants in the room and W1 declined to move R1.

On 8/21/2025 and 10/8/2025 LPA interviewed 5 Staff (S1 to S5). 5 out of 5 staff stated he/she is aware of the facility having ants. S1 states it was brought to his/her attention on 8/11/2025 by W1 and W2 that R1 had ants in his/her room and on his/her body. S1 states he/she notified the facility ADM about the ants in R1’s room and on R1’s body on 8/11/2025.

LPA interviewed 3 Residents (R1 to R3). 2 Out of 3 residents stated he/she has observed ants in his/her room but did not remember the date of these incidents. R1 did not respond to questions due to neurocognitive disorder.

LPA toured 7 resident rooms. In 3 Out of 7 resident bedrooms, LPA observed ant traps in the corners of the room, dead ants along the bedroom floorboard corners, ants crawling on the floor, ants on a windowsill, and ants crawling on the wall.

On 10/8/2025 LPA interviewed 2 Witnesses (W1 and W2). W1 stated on 8/11/2025 he/she visited R1 at approximately 9AM, and observed ants on R1’s pillow. W1 stated he/she observed ‘ants on the floor, crawling up R1’s bed and on R1’s beddings (blankets, sheets, pillow) and in R1’s hair’. W1 stated he/she also observed ants in R1’s diaper area. W1 stated R1 was non-verbal and cannot communicate his/her needs. W1 stated he/she told S1 about the ants on 8/11/2025. W1 stated he/she also spoke with S3 about the ants, and S3 told the ADM. W1 stated he/she was contacted by the ADM at approximately 4PM, where ADM offered to move R1 into another room. W1 stated that the room offered to R1 also had ants, and he/she declined to move R1 to the other room.
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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250820110316

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: 11/07/2025

NARRATIVE

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LPA interviewed W2. W2 stated on 8/11/2025 at approximately 10AM, he/she arrived at the facility and W1 spoke with him/her about the ants in R1’s room. W2 stated he/she observed ants on R1’s bed (headboard, footboard), and around R1’s floorboards of the room. W2 stated during a diaper change of R1, both he/she and W1 observed ants in R1’s brief. W2 stated he/she informed S2 about the incident.

Based on review of R1’s physician’s report dated 3/10/2025, R1 has neurocognitive disorder, and is unable to communicate his/her needs, as listed under Physical Health Status ‘i. Able to Communicate Needs-No.’

Based on review of R1’s Appraisal/Needs and Services Plan dated 6/30/2025, staff are to assist daily with R1’s Socialization Needs, Emotional Needs, Mental Needs, Physical/Mental Health Needs, and Functioning Skills Needs.

Review of R1’s Preplacement Appraisal Information dated 4/1/2025, R1’s Communication is listed as “having severe speech impairment…uses non-verbal communication…has few words…can answer yes or no.”

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations Title 22, are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided.

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END OF REPORT

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250820110316

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: 11/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/08/2025 Section Cited CCR 87468.1(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan of action stating how he will ensure resident’s rooms and residents are free of ants and submit the plan to CCLD by POC due date of 11/8/2025.
	8 9 10 11 12 13 14	Based on observation and interview, the Licensee did not ensure that R1’s room was free of ants, resulting in R1 having ants on his/her body on 8/11/2025. This poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Brenda Chan
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

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