097002991-9-9-2022-25-AS-APEZ-CJBLAW-20220916083543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:19:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
08/16/2021 and conducted by Evaluator Melissa Parks

COMPLAINT CONTROL NUMBER: 25-AS-20210816201752

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: 37	DATE:	09/09/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Jennifer Scarberry		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff not providing adequate service to resident(s) in care.

INVESTIGATION FINDINGS:

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LPA Parks arrived on September 9, 2022 to conclude a complaint investigation regarding the above allegations. Prior to the visit, LPA completed the required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

Throughout the course of the investigation, LPA interviewed staff, residents, and performed a document review. LPA was not able to determine that services were not provdied to residents in care. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Exit interview. Copy of report provided.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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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