092700445-11-16-2021-25-AS-LMUZ-C98NXM-20211129095119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700445
Report Date: 11/16/2021
Date Signed: 11/16/2021 03:03:33 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
07/21/2021 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 25-AS-20210721134721

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: 21	DATE:	11/16/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Gabriel Mendoza		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not assisting resident with cleaning her room.
Staff are not assisting resident with hygiene.
Residents hearing aids have been lost.
Staff are not adhering to the admission agreement.
Staff are not adhering to the residents care plan.
Residents representative has not been informed in changes in policy.

INVESTIGATION FINDINGS:

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

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 a mask and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Gabriel Mendoza.

Allegations:
Staff are not assisting resident with cleaning her room.
Complaint states: Room was not clean – Garbage down behind dresser, stains on wall behind dresser. Staff were notified and both areas were cleaned. There were also food stains on chair fabric. There were ants in the trash. During the LPAs inspection of the room, revealed that it was clean and tidy. Room was not unkempt. 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) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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 2

Control Number 25-AS-20210721134721

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: 11/16/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff are not assisting resident with hygiene.
Complaint stated that R1s hygiene looked a little lax. LPA was not able to observe R1. Documentation shows that R1 "prefers" a sponge bath. Charting notes indicate that the majority of the time R1 refuses to take a shower. LPA is not able to expound on this allegation due to lack of valid contact information with the complainant. Based on this, this allegation is UNSUBSTANTIATED.

Residents hearing aids have been lost.
Residents hearing aids were not listed on the property form when resident moved in. LPA is unable to expound on this allegation due to a lack of complainant contact information. Based on this, this allegation is UNSUBSTANTIATED.

Staff are not adhering to the admission agreement.
LPA is not able to expound on this allegation due to lack of valid contact information with the complainant . Based on this, this allegation is UNSUBSTANTIATED.

Staff are not adhering to the residents care plan.
LPA is not able to gather more information on this allegation due to a lack of contact information. Based on this, this allegation is UNSUBSTANTIATED.

Residents representative has not been informed in changes in policy.
LPA cannot expound on this allegation due to the lack of contact information is lacking. If in regards to the transportation policy, the policy for transportation is straightforward. Facility will only assist in transportation arrangements, not transport. According to Melisa Tiburcio, ED, they were transporting clients to medical / dental appointments time and staff permitting. Title 22 also states that they will make arrangements for transportation to the nearest services. The facility was transporting locally, as a courtesy for the residents but staffing issues have curtailed this courtesy. ED stated they have no problem arranging for transportation for the resident(s). Based on this, this allegation is UNSUBSTANTIATED.

As a result of this investigation, LPA finds the allegation that staff are not assisting resident with cleaning her room, staff are not assisting resident with hygiene, residents hearing aids have been lost, staff are not adhering to the admission agreement, staff are not adhering to the residents care plan and residents representative has not been informed in changes in policy 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: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2