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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 03/02/2021
Date Signed: 03/02/2021 11:39:04 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/15/2020 and conducted by Evaluator Michael Smith
COMPLAINT CONTROL NUMBER: 27-AS-20200115133115
FACILITY NAME:NEW WEST HAVEN IIFACILITY NUMBER:
097002991
ADMINISTRATOR:JOEL MATKOVICHFACILITY TYPE:
740
ADDRESS:2551 CAMEO LANETELEPHONE:
(530) 677-2979
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:67CENSUS: 19DATE:
03/02/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Earlene MartinTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility lacks sufficient staff to be able to meet residents' needs on a timely basis
INVESTIGATION FINDINGS:
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LPA Smith conducted an unannounced complaint visit and met with Earlene Martin.

The investigation shows that on the date in question 1/11/2020, the facility had 1 caregiver staff to 11 resident ratio during awake hours. The ratio of 1 caregiver per 11 residents during awake hours. There were 11 response times over 1 hour and 10 other response times that were over 30 minutes each, on the date in question. Title 22 requires sufficient staff to meet the needs of the residents. Response times of over 30 minutes x21 incidents does not meet this requirement. Thus, based on the investigation, this allegation is SUBSTANTIATED.

As a result of this investigation, LPA finds the allegation that the facility lacks sufficient staff to be able to meet residents' needs on a timely basis to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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 27-AS-20200115133115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW WEST HAVEN II
FACILITY NUMBER: 097002991
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/02/2021
Section Cited
CCR
87411(a)
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87411(a)-Personnel Requirements-General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the
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Facility shall have sufficient personnel at all times to provide the services necessary to meet residents needs. This shall be effective immediately.

***Deficiency cleared during visit***
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extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. Facility had a 1 to 11 ratio and resident response times were over 30 minutes x21 incidents on 1/11/20.
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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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC9099 (FAS) - (06/04)
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