092700445-6-4-2021-25-AS-MSEY-C3RNKJ-20210607103157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700445
Report Date: 06/02/2021
Date Signed: 06/04/2021 12:57:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2021 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 25-AS-20210520115752

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: 23	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Melisa Tiburcio		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility kitchen is not clean and sanitized

Facility has roaches

INVESTIGATION FINDINGS:

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Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore an N-95 respirator and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Melisa Tiburcio.

Allegations:
Facility kitchen is not clean and sanitized
LPA did a comprehensive inspection on 5/26/21. Areas inspected were the kitchen, walk in coolers, kitchen prep area, breakroom and laundry room. All areas inspected were immaculate, spotless and clean. Furnished pictures included dirty sinks, dirty stove top, food "left out" and a vat of used oil. The pictures revealed the normal use of a kitchen. Sinks will get dirty, stove top will be used, cooking oil needs to be replaced on a routine basis, food will be out for preparation. Based on LPAs unannounced spot inspection which revealed the kitchen and other facility areas being spotless and immaculate, 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) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

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 25-AS-20210520115752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PAVILION AT EL DORADO HILLS, THE	FACILITY NUMBER: 092700445
	VISIT DATE: 06/02/2021

NARRATIVE

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Facility has roaches
LPA was provided with the last 3 months of pest control documentation. Service dates were 2/24/21, 3/25/21 and 4/29/21. Services were performed by Ecolab Pest Elimination. Under "pest activity found" no findings were noted for all dates. Additionally, under "sanitation issues" there was only a reference to cut back exterior vegetation. All 3 months had specific target pest for roaches in the break room, kitchen, bathrooms, hallways and housekeeping areas. LPA's inspection did not show any signs of roaches, droppings or any evidence of pests. Facility provided documentation of proactive, routine pest control by a professional pest control company. As such, this allegation is UNSUBSTANTIATED.

As a result of this investigation, LPA finds the allegations that facility kitchen is not clean and sanitized and facility has roaches 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) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

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