092700445-6-26-2023-59-AS-LMUZ-CT7QZ3-20230627123603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700445
Report Date: 06/26/2023
Date Signed: 06/26/2023 10:44:18 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230424153422

FACILITY NAME:	PAVILION AT EL DORADO HILLS, THE		FACILITY NUMBER:	092700445
ADMINISTRATOR:	MELISA TIBURCIO		FACILITY TYPE:	740
ADDRESS:	2288 FRANCISCO DR		TELEPHONE:	(916) 542-3452
CITY:	EL DORADO HILLS	STATE: CA	ZIP CODE:	95762
CAPACITY:	64	CENSUS: 34	DATE:	06/26/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director James Hall		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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8
9

Staff failed to treat residents with dignity and respect.

INVESTIGATION FINDINGS:

1
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5
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13

On 6/26/2023, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Executive Director James Hall.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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 5

Control Number 59-AS-20230424153422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAVILION AT EL DORADO HILLS, THE	FACILITY NUMBER: 092700445
	VISIT DATE: 06/26/2023

NARRATIVE

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Staff failed to treat residents with dignity and respect.
Department conducted interviews with staff (4) and residents (4), records were reviewed, and facility observation was done to investigate this complaint allegation. As a result of the investigation: department finds residents are not being treated with respect by staff. Interviews indicated that S1 and S2 would yell at residents and came off abrasive at times when communicating to residents, which negatively impacts resident's sense of wellbeing. S1 and S2 were terminated by the facility for their actions and treatment to residents. As a result of this investigation, department finds the allegation(s) to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation(s) s valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6.

Exit interview with administrator. Appeals rights provided. Copy of the report provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 59-AS-20230424153422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAVILION AT EL DORADO HILLS, THE	FACILITY NUMBER: 092700445
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/27/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1(a)(1) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not evidence by:	1 2 3 4 5 6 7	Licensee agrees to submit a statement of understanding of this regulation to CCL by the POC date- 6/27/2023.
	8 9 10 11 12 13 14	Interviews indicated that facility staff verbally abused residents in care and did not treat residents with dignity and respect. This is an immediate risk to the health and safety of 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.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230424153422

FACILITY NAME:	PAVILION AT EL DORADO HILLS, THE		FACILITY NUMBER:	092700445
ADMINISTRATOR:	MELISA TIBURCIO		FACILITY TYPE:	740
ADDRESS:	2288 FRANCISCO DR		TELEPHONE:	(916) 542-3452
CITY:	EL DORADO HILLS	STATE: CA	ZIP CODE:	95762
CAPACITY:	64	CENSUS: 34	DATE:	06/26/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director James Hall		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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 5

Control Number 59-AS-20230424153422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAVILION AT EL DORADO HILLS, THE	FACILITY NUMBER: 092700445
	VISIT DATE: 06/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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21
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25
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27
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29
30
31
32

Staff handled resident in a rough manner.
Department conducted interviews with staff (4) and residents (4), records were reviewed, and facility observation was done to investigate this complaint allegation. During the investigative process, there was no information provided that indicated staff handled clients in a rough manner. Furthermore, there is no evidence showing the residents suffered any injuries by any staff. Based on the interviews conducted, the complaint is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

Exit interview with Executive Director. Copy of the report provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5