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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 08/18/2022
Date Signed: 08/24/2022 03:48:36 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
05/17/2022 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220517165901
FACILITY NAME:NEW WEST HAVEN IIFACILITY NUMBER:
097002991
ADMINISTRATOR:TANIA LANGLANDFACILITY TYPE:
740
ADDRESS:2551 CAMEO LANETELEPHONE:
(530) 677-2979
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:67CENSUS: 38DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lacey Ripoll, Med TechTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
Facility is unkept
INVESTIGATION FINDINGS:
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On 8/18/2022, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility and met with Med Tech Lacey Ripoll to conclude a complaint investigation into the allegations listed above. LPAs wore surgical mask and self-screened prior to entering.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (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 5
Control Number 25-AS-20220517165901
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: Resident sustained unexplained injuries while in care

Interviews conducted with Residents (R2-R7) indicate that facility staff treat them with quality care, and have never witnessed any staff being rough with them or any fellow residents. Reviewing R1's medication log, they were prescribed meds that are known blood thinners which can cause bruises.

Allegation: Facility is unkept

During visit conducted on 5/27/2022, the Department found the facility to be clean and in good repair. The Department did not witness unkept areas at the facility.

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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (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: 5 of 5
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
05/17/2022 and conducted by Evaluator Jacob Williams
COMPLAINT CONTROL NUMBER: 25-AS-20220517165901

FACILITY NAME:NEW WEST HAVEN IIFACILITY NUMBER:
097002991
ADMINISTRATOR:TANIA LANGLANDFACILITY TYPE:
740
ADDRESS:2551 CAMEO LANETELEPHONE:
(530) 677-2979
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:67CENSUS: 38DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lacey RipollTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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On 8/18/2022, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility and met with Med Tech, Lacey Ripoll, to conclude a complaint investigations into the allegation listed above. LPA wore surgical mask and self-screened prior to entering.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (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: 2 of 5
Control Number 25-AS-20220517165901
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 mismanaged resident's medication

The department reviewed pertinent documents and conducted interviews with residents (R2-R10). It was found that in R1's MAR, there is no documentation of 10 separate types of medications given to R1 for 26 days in April 2022. Per staff interview, all medication should either be given to resident or otherwise an explanation should be included why it was not able to be given, which was not done. Also through interviews, four residents noted significant issues with not receiving their appropriate medication.

Based on interviews and evidence obtained during the investigation, 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (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: 3 of 5
Control Number 25-AS-20220517165901
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 A
09/02/2022
Section Cited
CCR
87465(a)(5)
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87465(a)(5) Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee agrees to conduct an in-service medication training with all staff no later than 9/2/2022. Licensee will submit a copy of training and roster with signatures to LPA by 9/2/2022.
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Based on LPAs record review and interview, staff failed to provide medication to resident in a timely manner as prescribed. This poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Williams by 9/2/2022.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (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 5