486801837-1-21-2025-21-AS-BMOS-DDDSLG-20250129125815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801837
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:01:55 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2024 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20241021110127

FACILITY NAME:	PARADISE VALLEY RESIDENTIAL CARE HOME		FACILITY NUMBER:	486801837
ADMINISTRATOR:	GADIA, EDWARD		FACILITY TYPE:	740
ADDRESS:	524 AMERICANO WAY		TELEPHONE:	(707) 344-4744
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 6	DATE:	01/21/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee, Edward Gadia		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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-Resident sustained unexplained injury (s).

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cuadra and Magdaleno arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Licensee, Edward Gadia.

The Department received an allegation of resident sustained unexplained injury (s). Per SOC341 received from the reporting party, on 10/4/24 resident (R1) was complaining of wrist pain, they were observed with small purple bruises on their wrist and hand that did not indicate nothing unusual was happening to them, but the following week, R1 was complaining of pain, bruising was now yellowing, so the reporting party contacted R1’s physician, the doctor referred R1 to have x-rays done that revealed an acute fracture distal ulna diagnosis on 10/17/24 that it was suspected from any source of force. Based on confidential interviews conducted by LPA with staff (S1 and S2) indicates that about two to three weeks prior to the diagnosis of R1’s injury, R1 was complaining of pain, but it was within “normal” that R1 was complaining, but the following week upon concerns raised by an outside individual, staff notified the Licensee who instructed them to contact R1’s physician. Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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 21-AS-20241021110127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 486801837
	VISIT DATE: 01/21/2025

NARRATIVE

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Continued from LIC9099...

According to staff, R1 tends to hit the walls with their hands, developed combative behavior, refuses to drink enough water and have been recently diagnosed with urinary tract infection (UTI). Interviews conducted with residents (R2 & R2) did not reveal any witnessed incident of abuse. Based on records review, R1’s physician report dated 9/6/24 indicates that R1 has a diagnosis of hypertension and did not have a history of self-abuse or aggressive behavior condition prior to this incident. The facility provided daily progress notes indicating that on 3/19/24, staff have noticed a tendency of R1 to be slightly aggressive to them, R1 swing their arms at them, but neither R1’s physician’s report nor their care plan was updated on 9/4/24 reflecting how the facility will be handling any of these behaviors. Although, LPA is unable to determine the reason of R1’s fracture on their wrist. LPA have reviewed incident report logs from the facility that did not indicate the facility made a report to the Department about any incident and no further details were documented regarding any investigation been conducted by the facility. LPA will address reporting requirements and medical attention in a case management due to facility did not seek any further medical attention. A finding that the complaint allegation occurs of resident sustained unexplained injury while in care is unsubstantiated meaning 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.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC9099 (FAS) - (06/04)

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