Paradise Valley Estates

Allegation investigated: Personal Rights

On 08/20/2026 Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conducte a Personal Rights Complaint investigation recieved by Community Care Licensing (CCL) on 08/14/2026. LPA met with Administrator Shannon Stack and Assited Living Director Phyllicia Xiong who has Designation of Facility Responsibilty (RP) LPA made observations, obtained documents and conducted interviews. The above complaint was determined to be UNFOUNDED. A finding of unfounded means, the allegation was false, could not have happened and/or is without a reasonable basis. Report was reviewed with Responsible Party, whose signature denotes receipt. Unfoundedthe state’s words, verbatim · CDSS document, Aug 20, 2026 · control 21-AS-20260814154905

Type of visit: Case Management - Other

On 08/20/206 Licensing Program Analyst (LPA) Star Stevenson arrived unannounced on a Case Management Visit and met with Phyllicia Xiong Assistant Living Manager who has Designation of Responsibility (RP) The purpose of the Case Manage visit was to to ensure that the facilities Delayed Egress doors were labeled and working properly. A test of two (2) doors was conducted with both Delayed Egress doors of the Memory Care unit. Both doors were noted to sound an alarm upon attempted exit and then open after 15 seconds as required. In addition each door had red sign that read, "KEEP PUSHING. THIS DOOR WILL OPEN IN 15 SECONDS. ALARM WILL SOUND" Delayed Egress Doors are working and labeled as required by regulation. No citations are warranted. Signature of Responsible Party denotes receipt.the state’s words, verbatim · CDSS document, Aug 20, 2026

Type of visit: Case Management - Incident

At approximately 1:00 PM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced on a case management visit regarding a self-reported Unusual Incident Report (LIC624) received by the Department on 04/10/2026 in which a resident (R1) was able to open a memory care window in their room on the night of 04/09/2026 and place their walking device over an approximately 12" high by 15" wide concrete ledge and exit the building where they were later found by the security staff at the facilities guard shack inside the perimeter of Paradise Valley Estates. LPA notes that immediate notifications were made to R1’s Primary Care Physician (PCP), who was asked to evaluate R1 for consideration of medication changes related to sundowning and exit seeking behaviors. In addition, the spouse of R1 was immediately notified, with spouse of R1 noted to agree to the request of R1’s PCP to potentially adjust behavior medicines for R1. LPA obtained documents, made observations and conducted interviews around the inner-facility elopement of R1. It was revealed through the Physician Assessment (LIC602) and care note review that R1 can be “confused”, has known “wandering behavior” and “sundowning behavior”, requires “constant supervision” and is able to “ambulate without assistance”. It was also revealed through interview of S1 that R1 exited from their private apartment where they can be alone and it was from this apartment that R1 was able to push in a locking clamp of their ground level window and exit their apartment without staff initially knowing. Continued on LIC809C Continued for LIC809 Review of documents and interviews obtained during today's case management visit indicate staff moved quickly to remedy this potential danger for memory care residents and by the next morning Management and Communication/IT staff had placed an order for window alert alarms for all Memory Care resident room windows. In addition, interview with S1 revealed that a motion room sensor was placed in R1's room the night of the inner-facility elopement. (see photos of window sensor and room motion alarm) No deficiencies are cited. Report was reviewed with Assisted Living Manager whose signature here denotes receipt.the state’s words, verbatim · CDSS document, Apr 16, 2026

Type of visit: Case Management - Annual Continuation

At approximately 9:35 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to CONTINUE a required 1-year annual inspection and met with Phyllicia Xiong-Assisted Living Director. At approximately 9:45 AM LPA observed ten (10) staff files and four (4) of ten (10) staff files were missing evidence of 20 hours or training by the anniversary of the hire dates (a REPEAT- Type B citation is being issued for violation of HSC 1569.625(b)(2) and a civil penalty in the amount of $250 is being assessed) The same violation of HSC 1569.625(b)(2) occurred on 11/15/2024. HSC 1569.625(b)(2 requires 20 hours of annual training including dementia training and training in postural supports, restricted conditions and hospice care. See LIC811 for details. At approximately 11:15 AM LPA observed ten (10) random resident files from each of the three (3) assisted living buildings and determined that all 10 had the required documentation. LPA request an updated LIC500 be sent to Community Care Licensing by 12/14/2025 to update facility file. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Phyllicia Xiong-Assisted Living Director and Appeal rights were given.the state’s words, verbatim · CDSS document, Nov 14, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 9:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to BEGIN a required 1-year annual inspection and met with Phyllicia Xiong-Assisted Living Director and Sonja Duerst- Clinical Service Director. Facility is a Continuing Care Retirement Community (CCRC) with a combined total of 72 residents currently residing in the assisted living and memory care units. The community is approved for a total capacity of 743 residents, of which 223 residents may be non-ambulatory. The community has a hospice waiver for 6 residents, and there is an approved delayed egress system in place in the memory care unit. Deer Creek Memory Care Unit has a current census of 16. Quail Creek Assisted Living has a current census of 32 and Willow Creek Assisted Living has a current census of 25. At approximately 10:40 AM, LPA initiated a tour of the community's Quail Creek and Willow Creek Assisted Living Facilities and the Deer Creek Memory Care Facility and observed the following: The Quail Creek facility is a three story building and the Willow Creek and Deer Creek facilities are both one story. Each building was a comfortable temperature, and passageways were free from obstructions. LPA observed the required evacuation chairs in stairwells. Water temperature in 6 random resident bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. An staff service room in the Willow Creek Assisted Living unit, that is not readily accessed by residents was noted to have an odor and evidence of a warped and discolored melamine counter top and a technical advisory was issued to advise repair/replacement. LPA observed a supply of hygiene, paper, and incontinent care products available for residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets and storage rooms containing cleaning supplies and other items that could pose a risk were locked. Community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Food was covered, labeled, and stored in accordance with regulation. Medications were centrally stored and locked in all 3 building, including rooms and rolling lockable medicine carts. Continued on LIC809-C... Continued from LIC809... The community has a fitness center with a class schedule posted with multiple classes per day offered to residents, an indoor pool, tennis courts, a massage room, a beauty salon, daily activities, crafts, puzzles, music, movies, reading areas, and more for residents in care. There are covered patios and seating areas throughout the community with outdoor space for activities. A number of rooms were noted to contain various holiday decorations ready for year long celebrations. The community has internet service available to residents in care. The community's fire extinguishers were observed charged and were last serviced 11/2024, and additional extinguishers were being serviced during my inspection. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid bag in each building. Administrator states the community has several back up generators. At approximately 12:10 PM LPA observed the community's infection control plan last updated 11/03/2025 and the emergency disaster plan which was last updated 11/12/2025. Smoke and Carbon Monoxide detectors were last inspected 6/2024 and are inspected semi-annually. The automatic sprinkler system is inspected semi-annually and was last inspected June 2024. The community conducts regular monthly disaster drills, and the most recent drill was conducted 09/2025. At approximately 12:30 PM, LPA BEGAN file review of 10 staff files, LPA will need to return to continue staff file review, as well as, resident record file review. LPA obtained updated copies of the Emergency Disaster Plan LIC610D, updated Resident Roster LIC9020A and Updated Liability Insurance today. Technical advisory today was cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Phyllicia Xiong-Assisted Living Director whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Nov 13, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

At approximately 10:00 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced and met with Health Care Administrator - Kevin Hogan and Clinical Services Director (RN) Sonja Duerst to conduct a case management visit regarding an SOC341, Report of Suspected Dependent Adult/Elder Abuse, submitted to Community Care Licensing (CCL) on 07/07/2025. The purpose of SOC341 was to report possible financial abuse with a resident (R1). On 7/7/2025 at approximately 2pm, R1 who resides in the independent living area reported to the facility their concern of financial abuse by an individual(I1) after finding unapproved charges to R1's credit card for approximately $352 for wig/hair extensions made on 7/5/2025 on the website www.naduyla.com. Unapproved charges of approximately $352 to R1's credit card were confirmed by R1's Fiduciary (F1). R1 also reported other items missing from their apartment including cookies, Pepsi, candy and Tide pods, but was not aware of any loss of cash. Per R1, they had three personal caregivers, one personal caregiver (I2) does handle credit card purchases for R1 to buy groceries. R1’s credit card was cancelled to prevent further unauthorized charges. R1 reported to the facility that they have attempted to call the staffing agency to cancel I1 from coming back to assist them in the community. Facility made the proper notifications and SOC341 was completed and forwarded to the correct parties per regulation. During today’s visit, LPA reviewed R1’s physician report and evidence of use of a financial fiduciary was obtained, which indicates that R1 has the capacity and ability to make their own financial decisions without facility assistance. The facility has conducted their internal investigations and LPA obtained pertinent documentation to review and determine if any further actions are needed. On 07/08/2025 LPA was informed that law enforcement began an investigation with case number 2507070163 assigned. No citations issued during today's visit.the state’s words, verbatim · CDSS document, Jul 11, 2025

Allegation investigated: Questionable Death

On 12/5/2024, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to delivered findings for the above allegation. LPA conducted 10-day on 9/20/2024 and obtained records and made observations. The complainant alleges that Resident 1 (R1) was not given a medication for nine days resulting in R1’s death. The Department reviewed records, conducted interviews with outside medical professional, obtained medical records and death certificate. R1 moved into the facility on 8/31/2024 and on 9/9/2024 R1 was transported to the hospital due to an observed medical emergency. The Department received a self-reported incident report (9/12/2024) informing that there was an error with R1s medication at intake resulting in R1 not receiving a medication for nine days. R1 passed away on 9/15/2024 after being admitted to hospice. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Interview with doctor overseeing R1s care revealed that due to R1s medical diagnosis and medical history they are unable to confirm that R1s death was a result of medication mismanagement. The medication that was not administered for nine days is prescribed to reduce the risk of blood clot; however, that risk does not completely go away by taking the medication. The death certificate was obtained and did not reveal evidence to support R1s death was a result of medication mismanagement. Although this allegation may be true, based upon the statements made, documents reviewed, as well as site visit observations, there is not a preponderance of evidence to prove the allegation is or, is not, true. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Continued from LIC9099A... A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited per Title 22 Regulations, Division 6, (See LIC9099D). Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Appeal rights provided.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 21-AS-20240919154700

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 6, 2024

87465 Incidental Medical and Dental Care .... (4)The licensee shall assist residents with self administered medications as needed. This regulation was not met as evidenced by: Licensee failed to ensure that all of R1's medications were properly documented upon the intake which led to one medication being left off of R1's daily medication administration record and the medication not being given for 9 days.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee conducted medication training on the importance of proper and accurate medication documentation and anticoagulant therapy. Additionally, facility has updated their policy regarding the reconciliation of medications and conducted an in person training on this updated policy.

Type of visit: Case Management - Annual Continuation

At approximately 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Kelly Yee, Administrator. Facility is a Continuing Care Retirement Community (CCRC) with a combined total of 69 residents currently residing in the assisted living and memory care units. The community is approved for a total capacity of 743 residents, of which 223 residents may be non-ambulatory. The community has a Hospice waiver for 6 residents, and there is an approved delayed egress system in place in the memory care unit. At approximately 10:10 AM, LPA initiated a tour of the community's Quail Creek and Willow Creek Assisted Living Facilities and the Deer Creek Memory Care Facility and observed the following: The Quail Creek facility is a three story building and the Willow Creek and Deer Creek facilities are both one story. Each building was a comfortable temperature, and passageways were free from obstructions. LPA observed the required evacuation chairs in stairwells. Water temperature in 4 of 16 residents' bathrooms measured outside the allowable range of 105 to 120 degrees F per Title 22 regulations, (see LIC809D). LPA observed a supply of hygiene, paper, and incontinent care products available for residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets and storage rooms containing cleaning supplies and other items that could pose a risk were locked. Community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Food was covered, labeled, and stored in accordance with regulation. LPA advised the head chef in both the Quail Creek and Willow Creek kitchens to ensure that all expired food is consumed or disposed of by the expiry date. Medications were centrally stored and locked. The community has a fitness center with a class schedule posted with multiple classes per day offered to residents, an indoor pool, tennis courts, a massage room, a beauty salon, daily activities, crafts, puzzles, music, movies, reading areas, and more for residents in care. Continued on LIC809-C... Continued from LIC809... There are covered patios and seating areas throughout the community with outdoor space for activities. The community has internet service available to residents in care. The community's fire extinguishers were observed charged and were last serviced 11/2023. Smoke and Carbon Monoxide detectors were last inspected 6/2024 and are inspected semi-annually. The automatic sprinkler system is inspected semi-annually and was last inspected 8/2024. The community conducts regular monthly disaster drills, and the most recent drill was conducted 10/2024. LPA observed the community's infection control plan and the emergency disaster plan which was last updated 12/2023. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid bag in each building. Administrator states the community has several back up generators. At approximately 12:30 PM, LPA began file review of 10 staff files and 10 resident files. 7 out of 10 resident files reviewed did not have the Needs and Services Plan signed and dated by the resident and/or their responsible party, (see LIC809D). Administrator advised to ensure all forms are signed and dated, including consent for emergency medical treatment and personal rights. 10 out 10 resident files reviewed had all the remaining required documentation. 7 out of 10 staff files reviewed were missing the required first aid training, (See LIC809D). 4 of 10 staff files reviewed were short of the some of the specific annual training hours required, (see LIC809D). LPA advised Administrator to ensure that the required initial training hours are documented in accordance with regulation. 10 out 10 staff files reviewed had all the remaining required documentation. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC610- Emergency Disaster Plan A copy of community Liability Insurance The following deficiencies were observed and cited (see LIC 809-Ds) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Nov 15, 2024

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 10:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Kelly Yee, Administrator. Facility is a Continuing Care Retirement Community (CCRC) with a combined total of 72 residents currently residing in the independent living, assisted living, and memory care units. The Community is approved for a total capacity of 743 residents, of which 223 residents may be non-ambulatory. The Community has a Hospice waiver for 6 residents, and there is an approved delayed egress system in place in the memory care unit. At approximately 10:30 AM, LPA requested staff and resident rosters. LPA experienced technical difficulties which made staff roster and Guardian verification take several hours to complete. LPA reported the issues to CCL Department managers and RM. Facility's staff are all background screened, cleared, and associated to the facility as required per regulation. LPA will return at a later date to complete the annual inspection. No deficiencies cited during today's visit. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Nov 8, 2024

The state marks this report as 8 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 10/31/2024, at approximately 11:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived to the Quail Creek Assisted Living building in this Continuing Care Retirement Community (CCRC) unannounced to conduct a Case Management - Incident visit regarding a Report of Suspected Dependent Adult/Elder Abuse form SOC341, received by CCL on 10/17/2024. LPA met with Kelly Yee, Assisted Living Manager (ALM), who over sees both of the community's assisted living buildings, and who informed LPA that Resident 1 (R1) resides in the Willow Creek Assisted Living building of the community. LPA gathered documentation and interviewed ALM before proceeding to the Willow Creek building to interview R1. The report, received by CCL on 10/17/2024, states R1 reported that Staff 1 (S1) "grabbed her 'because she didn't like what I said, and I have a bruise.' No bruise noted." Additionally, the report states that R1 "was unable to tell when incident occurred. Further, the report states that the responsible party, local law enforcement, and the Ombudsman were notified on 10/17/2024 as required. LPA followed up via telephone the same day and spoke with ALM. LPA requested ALM take photos of R1's arms if she would consent to it and send them to LPA. ALM later emailed LPA stating R1 refused having photos taken and when asked again when the incident occurred, ALM reported that R1 stated, "2 weeks to maybe a month ago. I really can't remember." Today, 10/31/2024, ALM provided LPA with notes regarding their interview with accused S1, which states S1 was unsure of any recent interaction except a time when they observed R1's spouse attempting to help transfer R1 and staff stated they were concerned about the spouses back and intervened to assist with the transfer. S1 stated that R1 became agitated and upset because they wanted their spouse to transfer them. ALM noted that S1 was instructed not to be alone with R1 and to always have another staff member present when interacting with R1 in their room. Continued on LIC809C... Continued from LIC809... Additionally, LPA obtained a copy of the police incident report, which states R1 declined police contact and interview, facility's interdisciplinary notes regarding R1's temperament, interactions, and conversations about the reported incident, including visit notes from a Social Services Counselor where R1 and their spouse reported no concerns. LPA also was informed that the social worker requested a Neurological/Psychiatric consultation which has already been conducted but facility has not received a copy the report yet, and the doctor who performed the visit is currently out of the country. R1's care plan dated 07/23/2024 states occasional memory loss. LPA was unable to interview S1 due to S1 currently being out of work with COVID. At approximately 1:00 PM, LPA proceeded to the Willow Creek Assisted Living building in the community with ALM to conduct interview with R1, who reported that the incident occurred about a month ago, and they did not report it, because "I was a chicken." R1 stated really liking S1 and does not think it was intentional. S1 reporting feeling that S1 was trying to be helpful. R1 provided conflicting statements and appeared confused. R1 had no concerns to report. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to ALM. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 31, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Julie Florio arrived to the assisted living building in this Continuing Care Retirement Community (CCRC) unannounced to conduct a required 24-hour Case Management - Incident visit regarding an Unusual Incident Report (UIR), received by CCL on 9/12/2024. The UIR stated a Resident (R1) did not receive their Warfarin for nine (9) days, became unresponsive on 9/9/2024, was sent to the ER, and was then transferred to UC Davis Medical Center (UCDMC). Upon telephone follow up and email communications with Kelly Yee, Assisted Living Manager, on Monday, September 16, 2024, LPA was informed the R1 passed away on Sunday, September 15, 2024 at 8:00 PM at UCDMC. Today, 9/17/2024, LPA met with Kelly Yee, Assisted Living Manager, and obtained documents, to include R1's admissions agreement and Death Report, not already received by CCL. Kelly states the facility is still waiting on R1's medical records and death certificate but will submit them to CCL upon receipt. A cause of death is still unknown by the facility at this time. At approximately 9:45 AM, Kevin Hogan, Health Care Administrator arrived and stated he "would like to be a part of this" investigation. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Manager. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 17, 2024

Allegation investigated: Facility failed to meet residents incontinent care needs.

Licensing Program Analyst (LPA) Julie Florio arrived unannounced at this facility to deliver findings of above allegation. LPA met with Administrator, Kevin J. Hogan. LPA conducted 10-day on 5/14/2024 and was informed that resident (R1) resides in the skilled nursing facility (SNF) portion of the community. LPA obtained documentation to confirm and cross reported allegation and concerns to Department of Public Health. Although CCL issues the license for Continuing Care Retirement Community (CCRC), CCL does not have jurisdiction to investigate above allegation. R1 as of 5/15/2024. no longer resides in the SNF. Based on record review, interviews conducted, and observations made, the allegation of facility failed to meet residents incontinent care needs is UNFOUNDED. A finding that the complaint is unfounded means that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, May 23, 2024 · control 21-AS-20240509082643