092700445-3-22-2021-27-AS-KHOS-BZENWT-20210324105004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700445
Report Date: 03/22/2021
Date Signed: 03/22/2021 11:56:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2021 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 27-AS-20210224083536

FACILITY NAME:	PAVILION AT EL DORADO HILLS, THE		FACILITY NUMBER:	092700445
ADMINISTRATOR:	DONNA B. COLMENARES		FACILITY TYPE:	740
ADDRESS:	2288 FRANCISCO DR		TELEPHONE:	(916) 542-3452
CITY:	EL DORADO HILLS	STATE: CA	ZIP CODE:	95762
CAPACITY:	64	CENSUS: 25	DATE:	03/22/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Sarah Holmes		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident experienced unexplained weight loss

Staff did not assist resident with medication in a timely manner

Facility is understaffed

INVESTIGATION FINDINGS:

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LPA Smith conducted an unannounced complaint visit and met with Sarah Holmes.

Note* This complaint does not identify any residents or dates that these allegations may or may not have occurred. LPA sent an email to the listed email address with no response.

Allegations-
Resident experienced unexplained weight loss
There was only 1 known resident that has experienced any weight loss. The investigation revealed that there are valid medical reasons that this individual is losing weight. As previously mentioned, the complaint does not identify any specific resident. Based on this, this allegation is UNSUBSTANTIATED.

Staff did not assist resident with medication in a timely manner
Facility staff are perplexed as to who the resident could be regarding this allegation. There have been no known medication issues / errors in recent memory with any resident. Complainant did not identify any specific resident. Based on this, this allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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 27-AS-20210224083536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PAVILION AT EL DORADO HILLS, THE	FACILITY NUMBER: 092700445
	VISIT DATE: 03/22/2021

NARRATIVE

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Facility is understaffed
During the 10 day initial visit, LPA observed 6 care giving staff and a total of 12 staff members physically present for 25 residents. Complainant did not identify any dates that the facility was understaffed. Based on this, this allegation is UNSUBSTANTIATED.

As a result of this investigation, LPA finds the allegation that resident experienced unexplained weight loss, staff did not assist resident with medication in a timely manner and facility is understaffed to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

LIC9099 (FAS) - (06/04)

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