097002991-3-21-2023-59-AS-LMUN-CQ5PL6-20230321112413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 097002991
Report Date: 03/21/2023
Date Signed: 03/21/2023 11:24:23 AM

Document Has Been Signed on 03/21/2023 11:24 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 of failure to seek medical attention in a timely manner. 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 August 5, 2021, the Department concluded an investigation for allegations that staff did not seek medical attention in a timely manner and staff did not notify authorized representative in charge of health conditions. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on interviews with facility staff, medical staff and R1’s responsible party and facility and hospital medical records reviewed, the Department determined that R1 had a fall on April 27, 2021 and had experienced pain after the incident. The facility did not seek immediate medical attention after the fall or when the R1 first complained of subsequent pain. On May 3, 2021, R1's leg was warm to the touch, purple, and swollen. The facility did not inform R1's Power of Attorney about the fall and pain until R1 was finally sent to the hospital on May 3, 2021. At the time of admission, R1 was diagnosed with acute deep vein thrombosis (DVT) of popliteal vein of left lower extremity and closed displaced intertrochanteric fracture of left femur. R1 was discharged back to the facility on Hospice and passed away on May 24, 2021. R1’s death report listed cause of death as Congestive Heart Failure, and Aortic Stenosis. Other significant conditions are listed as: Atrial Fibrillation and Dementia. Continued on the 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

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
26
27
28
29
30
31
32

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

§ 87465(g) Incidental Medical and Dental Care - (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in § 87469(c)(2), (c)(3), or (c)(4).

§ 87468.1(a)(8) Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.

At the time of the visit, no immediate civil penalty was issued to the facility.

On September 16, 2021, the Department conducted a non-compliance conference with the Licensee. At the time of the office meeting, the issuance of an immediate civil penalty for $500 was issued regarding the incident described above and the Licensee was informed that an additional civil penalty may be assessed at a future date per Health and Safety Code § 1569.49(f).

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 the facility’s failure to obtain timely medical care for the resident between approximately April 27, 2021 and May 3, 2021 after a fall resulting in the resident suffering a fracture of the left femur and acute deep vein thrombosis.

Continued on the 809-C

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)

Page: 3 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

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
26
27
28
29
30
31
32

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. However, since an immediate civil penalty of $500 was previously issued on September 15, 2022, the amount of the civil penalty issued today will be $9500.
 
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)

Page: 2 of 3