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

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:19:02 PM

Substantiated

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:	02:20 PM
MET WITH:	Jennifer Scarberry		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident wasn’t provided medications as prescribed
Face mask are not being worn

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 and residents. LPA reviewed documents pertaining to R1 including medication administration record (MAR), medication list, and activity of daily living reports (ADL). Based on observation, upon entering the facility, no staff were wearing masks. Additionally, based on interview of staff and residents, staff do not consistently wear masks when interacting with residents. Therefore, the allegation that face masks are not being worn is SUBSTANTIATED.

Substantiated

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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Control Number 25-AS-20210816201752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
	VISIT DATE: 09/09/2022

NARRATIVE

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Based on interviews and review of documentation, medications are often not routinely given or given correctly. Based on the review of R1’s MAR, the following dates do not show the prescribed medication Lorazepam as being given (Note all dates are from 2021) : August 2 at 8am and 4pm, August 4 at 12am, 4 am, 8am, and 12 pm, August 5th at 4pm and 8pm, August 6 at 8am and 12 pm, and August 7th at 8am and 12 pm. Therefore, the allegation that resident was not provided medications as prescribed is SUBSTANTIATED.

As a result of this investigation, the Department finds the allegations to be Substantiated.
A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview conducted. Appeal rights were given. A copy of this report was left at the facility.

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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210816201752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/12/2022 Section Cited CCR 87645(a)(5)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Administrator to submit training plan and schedule for med techs by end of day Monday.
	8 9 10 11 12 13 14	based on interview and MAR document review, residnet was not given medication as prescribed.	8 9 10 11 12 13 14
Type B 09/23/2022 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	Personal Rights. (a) Each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator to submit proof of training for all staff regarding facility's mask policy
	8 9 10 11 12 13 14	Based on observation and interview, masks were not consistently being worn by staff.	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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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