092700445-10-5-2022-25-AS-LMUZ-CJXNZ2-20221006105333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700445
Report Date: 10/05/2022
Date Signed: 10/05/2022 01:00:27 PM

Unsubstantiated

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
05/10/2022 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220510105311

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: 26	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Kent Mulkey, Executive Director		TIME COMPLETED:	01:26 PM

ALLEGATION(S):

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Residents are not getting showers timely
Staff are not assisting residents timely due to lack of staff
Residents are being left in soiled diapers

INVESTIGATION FINDINGS:

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On October 5, 2022, at 12:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for Complaint # 25-AS-20220510105311. LPA met with , Executive Director, Kent Mulkey, and explained purpose of the visit.

Prior to initiating the inspection LPA completed COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore an N-95 mask for Personal Protective Equipment (PPE). Additionally, LPA was screened by the front desk personnel upon arrival.

To continue see 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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-20220510105311

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: 10/05/2022

NARRATIVE

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The Department received a complaint alleging the facility staff are not showering residents timely, residents are left in soiled clothing for an extended period of time and staff are not assisting residents timely due to lack of staff. LPA reviewed resident files and interviewed staff and residents. The findings are as follows:

Residents are not getting showers timely

The residents who were interviewed were not able to communicate with LPA due to diagnosis of Dementia. All residents at the facility have a diagnosis of dementia. Staff stated in interviews that staffing can be challenging, but staff are still able to meet the needs of all residents in care. Staff also stated in interviews that if a care staff calls in, then a staff from management will fill in. Executive director stated that the facility no longer utilizes an outside staffing agency because they are fully staffed and have staff working overtime that can cover shifts. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Residents left in soiled clothing for extended periods of time.
Residents who were interviewed were not able to fully communicate with LPA due to diagnosis of Dementia. Staff 1 (S1) stated that sometimes residents refused, but there are multiple attempts to assist residents through distractions, and/or call for additional assistance from another staff. Staff stated that when they do find a resident with soiled clothing, they will immediately assist the resident. Staff stated that some residents can get soiled quickly due to the medications that residents take. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

To continue see 9099-C2...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20220510105311

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: 10/05/2022

NARRATIVE

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Staff are not assisting residents timely due to lack of staff
It was alleged that in the month of April 2022, resident’s needs were not being met due to lack of staff. An investigation was conducted, and the previous executive director, a caregiver, a Med tech, and the current executive director were interviewed. In addition, documents that were reviewed, included, shower and laundry schedule, and logs with a checklist of two hour checks by facility staff persons.
During the interview process, the executive director reported that he was not working during the time of the allegation; therefore, he was not able to comment. All the staff persons indicated that the allegation is untrue and that it was reported that at times, staff may have had a shortage of staffing; however, the staff were always available to meet the resident’s needs.
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, the findings are UNSUBSTANTIATED.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy of this report was given to Kent.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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