097002991-8-16-2023-59-AS-LMUZ-CUTPY9-20230818114335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 08/16/2023
Date Signed: 08/16/2023 11:30:03 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230405155446

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: 29	DATE:	08/16/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Jennifer Scarberry		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff gave wrong medications to a resident

INVESTIGATION FINDINGS:

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On 8/16/2023, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to conduct interviews and deliver complaint findings into the allegations listed above and met with Administrator Jennifer Scarberry.

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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 59-AS-20230405155446

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
	VISIT DATE: 08/16/2023

NARRATIVE

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Facility staff gave wrong medications to a resident.
During the course of the investigation for the above allegation, the department conducted interviews and record reviews. Department investigated allegation “Facility staff gave wrong medications to a resident” and interviewed staff. During interviews with staff, and records reviewed; it was determined that, staff dispensed the wrong medication to a resident in care, to be substantiated. Department received an incident report on a LIC624 regarding the medication error involving R1. Through documentation reviewed, it was determined that staff distributed mediation to R1 in error. The facility documented the medication error and did seek medical observation and treatment for R1 following the error.

Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview with administrator. Appeals rights provided. Copy of the report provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230405155446

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/17/2023 Section Cited CCR 80075(b)(5)(B)	1 2 3 4 5 6 7	80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to submit a self-certification in regard to providing medication training for all staff regarding medication administration and submit proof to LPA by POC date- 8/17/2023.
	8 9 10 11 12 13 14	Based on record reviewed and interviews, R1 was given the wrong medications in error. These medications were not ordered by R1s physician, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC9099 (FAS) - (06/04)

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