097002991-2-1-2021-27-AS-KHOS-BXUMSG-20210202085154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 02/01/2021
Date Signed: 02/01/2021 03:08:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
01/03/2020 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 27-AS-20200103090928

FACILITY NAME:	NEW WEST HAVEN II		FACILITY NUMBER:	097002991
ADMINISTRATOR:	JOEL MATKOVICH		FACILITY TYPE:	740
ADDRESS:	2551 CAMEO LANE		TELEPHONE:	(530) 677-2979
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	67	CENSUS:	DATE:	02/01/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sandra Aguilar		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff failed to meet residents care needs

Staff failed to keep residents room clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst Michael Smith contacted the facility via telephone to close the above allegations via telephone due to COVID-19 and pre-cautionary measures. LPA discussed the findings with Sandra Aguilar, Staff member.

Allegations: Staff failed to meet residents care needs
Facility was instructed to clean resident catheter as required and directed by the hospice agency. Witness statements reflect that the catheter was not being cleaned 2x daily. This was evidenced by several days of crusted dried urine and dried feces on the resident. Hospice agency instructed facility staff and even left written instructions on how to clean the catheter. Resident sustained multiple UTIs as a result of this.

Staff failed to keep residents room clean
Witness statements showed that the resident's toilet was not cleaned regularly. Several incidents where dirty bathroom linen was left for processing by the facility. Witness statements shows that the linen was left for at least 4 days in the bathroom and was never gathered to be cleaned.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

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-20200103090928

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
	VISIT DATE: 02/01/2021

NARRATIVE

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As a result of this investigation, LPA finds the allegations that staff failed to meet residents care needs and staff failed to keep residents room clean 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.

An exit interview was conducted with Sandra Aguilar, Staff member via telephone and a copy of this report will be provided to the facility via United States Postal Service. Two copies will be sent to the facility, 1 is to be signed and returned to CCL and the other copy is to be retained by the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200103090928

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/01/2021 Section Cited CCR 87633(6)(A)	1 2 3 4 5 6 7	87633-Hospice Care of Terminally Ill Residents-The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control. This requirement is not met as	1 2 3 4 5 6 7	Facility shall submit a written plan of action in order to prevent a recurrence of this situation. This shall be done within 7 days upon receipt of this document. Facility shall forward a copy to the LPA to clear this deficiency.
	8 9 10 11 12 13 14	evidenced by: Based on witness statements, licensee did not provide catheter care as directed by the hospice agency along with written instructions on the care to be provided and is in violation of this section. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Request Denied Type B 02/01/2021 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	87303(a)(1)-Maintenance and Operation Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on witness statements it was observed that dirty laundry was left on	1 2 3 4 5 6 7	Facility shall submit a written plan of action in order to prevent a recurrence of this situation. This shall be done within 7 days upon receipt of this document.. Facility shall forward a copy to the LPA to clear this deficiency.
	8 9 10 11 12 13 14	the floor of the residents bathroom for at least 4 days. Additionally, toilet was not being routinely cleaned. Licensee is in violation of this section. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

LIC9099 (FAS) - (06/04)

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