097002991-3-21-2023-59-AS-LMUN-CQ5PKR-20230321112330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 097002991
Report Date: 03/21/2023
Date Signed: 03/21/2023 11:23:41 AM

Document Has Been Signed on 03/21/2023 11:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

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: 32	DATE:	03/21/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Jennifer Scarberry		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On March 21, 2023, Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM) Laura Munoz conducted a case management inspection to follow up on a substantiated allegation resident because severely dehydrated resulting in hospitalization due to lack of care and supervision. LPA and LPM spoke to Licensee, Joel Matkovich on the phone and met with Administrator, Jennifer Scarberry and explained the purpose of the visit. On May 13, 2019, the Department concluded a complaint investigation for allegations that a resident (R1) became severely dehydrated resulting in hospitalization. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Throughout the course of the investigation, the Department conducted interviews with former staff, current staff, and R1’s family member who will be referred to as W1; reviewed EMS reports, hospital records, and facility records, including but not limited to: RTask notes, service recaps, incident reports, and R1’s facility file. Continuation on 809C...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
	VISIT DATE: 03/21/2023

NARRATIVE

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The Department reviewed the facility’s ongoing notes, RTask Campus Memo History, from February 10, 2018, to September 25, 2018. Notes on September 5, 2018, at 6:58 p.m., indicated a staff member entered a note stating R1 complained of lower back and stomach pain but refused medication. Memo further stated, “So please keep an eye on R1, maybe we could call R1’s son an[d] see if he can get R1 a dr. appt about their back.” No other notes are available for R1 after September 5, 2018. Staff (S2) stated that R1 wasn’t eating as much as the week prior due to back pain, and that for about two (2) days, R1 wasn’t getting out of bed. Staff (S3) stated R1 “didn’t look good” the last two (2) days at the facility, and that R1 had stayed in bed those days. S3 further stated that R1 refused one meal per day for about a week leading up to R1 going to the emergency room.

Medical documents reviewed show that R1 was admitted to the emergency room on September 25, 2018, after facility staff contacted 9-1-1 because R1 was found in their room in an altered state of consciousness. Hospital records reviewed stated R1 was diagnosed with: hypernatremia (high sodium in the blood that is often caused by dehydration), acute kidney injury on chronic kidney disease stage III, methicillin-resistant staphylococcus aureus positive, leukocytosis reactive, and atrial fibrillation with rapid ventricular response. Medical reports indicated the acute kidney injury was from dehydration. EMS report from September 25, 2018, stated that, “care facility staff states pt has been bed confined for 2 weeks and also has had slurred speech times 2 days.” R1’s planned services provided by the facility stated that R1 was to have hydration recorded and for staff to push fluids. Service Recap from dates September 2, 2018, to September 25, 2018, provided by the facility show that the last time R1’s hydration was recorded was on September 17, 2018, and the last time push fluids was recorded was September 18, 2018. RTasks notes from dates September 9, 2018, to September 25, 2018, provided by the facility show the last recorded amount of “hydration” at 8:53 p.m. on September 18, 2018, in the amount of “4 oz of fluid.” There were no records on hydration for R1 after September 18. 2018. Current and former staff members told the Department that R1 needed reminders to drink water, and that hydration was supposed to be recorded for how many fluids R1 was getting. In interviews with Staff (S1), S1 stated R1’s condition “went way too far,” and R1 should have gotten more medical attention sooner than R1 did. S1 further stated that it was difficult to know how much liquid R1 was given because R1’s liquid intake was not properly documented.

Continuation on 809C ...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
	VISIT DATE: 03/21/2023

NARRATIVE

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The above allegations were substantiated, and deficiencies were cited for violating the following California Code of Regulations (CCR) Title 22:

87464 Basic Services (f)(1)
Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.

87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
 
The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by facility staff did not follow R1’s needs and service plan by providing R1 adequate liquids which resulted in R1 becoming dehydrated. The facility did not seek timely medication attention when (R1) became severely dehydrated resulting in hospitalization for acute kidney injury.

Today, March 21, 2023, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation the Department constitutes as a serious bodily injury.

A copy of the LIC 421D was given to the facility representative. 

Exit interview conducted.  Appeal Rights provided.  A copy of the report issued.  Signature on these reports acknowledges receipt of these rights, found on page 2 of LIC 421D. 

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC809 (FAS) - (06/04)

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