097002991-8-18-2022-25-AS-APEZ-CHNTC9-20220826143622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 08/18/2022
Date Signed: 08/18/2022 05:18:31 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
04/27/2022 and conducted by Evaluator Jacob Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220427095808

FACILITY NAME:	NEW WEST HAVEN II		FACILITY NUMBER:	097002991
ADMINISTRATOR:	TANIA LANGLAND		FACILITY TYPE:	740
ADDRESS:	2551 CAMEO LANE		TELEPHONE:	(530) 677-2979
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	67	CENSUS: 38	DATE:	08/18/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lacey Ripoll, Med Tech		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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9

Staff failed to respond to resident's call assistance button in a timely manner
Staff left resident in soiled diaper for extended period of time
Facility is malodorous

INVESTIGATION FINDINGS:

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7
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9
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12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

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 4

Control Number 25-AS-20220427095808

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: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
	VISIT DATE: 08/18/2022

NARRATIVE

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Allegation: Staff failed to respond to resident's call assistance button in a timely manner

Based on document review and interviews of R2-R10, two residents complained of experiencing wait times of 1 hour once alerting their pendant.

Allegation: Staff left resident in soiled diaper for extended period of time

Interviews conducted with Residents (R2-R10) indicate that facility staff assist residents with continence care within in a reasonable amount of time.

Allegation: Facility is malodorous

During visit conducted on 8/18/2022 the Department found the facility to be clean and in good repair. LPA entered the room in question and did not notice an unpleasant odor. Through interviews of R2-R10, no residents complained of malodor.

Based on interviews conducted by the Department and observation, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
04/27/2022 and conducted by Evaluator Jacob Williams

COMPLAINT CONTROL NUMBER: 25-AS-20220427095808

FACILITY NAME:	NEW WEST HAVEN II		FACILITY NUMBER:	097002991
ADMINISTRATOR:	TANIA LANGLAND		FACILITY TYPE:	740
ADDRESS:	2551 CAMEO LANE		TELEPHONE:	(530) 677-2979
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	67	CENSUS: 38	DATE:	08/18/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lacey Ripoll, Med Tech		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility has insufficient staffing to meet the residents’ needs

INVESTIGATION FINDINGS:

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7
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9
10
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12
13

On 8/18/2022, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility and met with Lacey Ripoll, Med Tech, to conclude a complaint investigation into the allegations listed above. LPA wore surgical mask and self-screened prior to entering.

Based on interview statements of S1-S4 and documents obtained, Two staff stated they are not able to perform their job adequately for each resident due to lack of staffing. S2 stated there have been many complaints from family about lack of staffing. Four residents complained of med errors, which the department believes is due in part to Med Tech being pulled to assist in other areas. S3 states they see lapses in care daily due to being understaffed.

The preponderance of evidence standard has been met, therefore, the allegation are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20220427095808

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: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/02/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.	1 2 3 4 5 6 7	Licensee shall submit an action plan explaining what steps the facility will take to maintain sufficient staff to meet residents needs. Please submit to:CCLD no later than POC date of 9/2/2022.
	8 9 10 11 12 13 14	This requirement is not met based on records and statements that found residents have lapses in care and missed medications due to insufficient staff. This posed an immediate risk to residents health and safety.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4