092700445-8-5-2021-27-AS-LMUZ-C5TUFQ-20210812153305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700445
Report Date: 08/05/2021
Date Signed: 08/05/2021 01:09:15 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
01/08/2021 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 27-AS-20210108164658

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: 21	DATE:	08/05/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Melisa Tiburcio		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Lack of Supervision

Record keeping

Medications are not being given to residents

Medications are not being properly destructed

Facility does not have adequate staffing to meet residents needs

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.

LPA is unable to contact complainant based on a lack of contact information. Complaint is devoid of specific names of staff / residents, dates of alleged occurrences, witnesses, etc. The lack of identifying information and witnesses that are required to investigate this complaint are absent. Based on this, these allegations are UNSUBSTANTIATED

As a result of this investigation, LPA finds the allegations that there is a lack of supervision, record keeping medications are not being given to residents, medications are not being properly destructed and facility does not have adequate staffing to meet residents needs 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.

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: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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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