097002991-3-22-2021-27-AS-KHOS-BZENP3-20210324103741

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 03/22/2021
Date Signed: 03/22/2021 10:54:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2020 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 27-AS-20200505124837

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: 19	DATE:	03/22/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kitty Flannagan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident has not been adequately fed resulting in weight loss

Resident has not been adequately hydrated resulting in dehydration

Insufficient staff to meet resident's needs

INVESTIGATION FINDINGS:

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LPA Smith conducted an unannounced complaint visit and met with Kitty Flannagan.

Allegations:

Resident has not been adequately fed resulting in weight loss
On 5/6/20 the medical records noted that there has been a 20 lb weight loss in 7 months. However, patient has had a rapid physical and cognitive decline over the last 2 months, she is non-responsive, has not had anything to eat or drink for 3 days and requires total care. Hospice RN discouraged facility staff or patient family from forcing the patient to eat or drink due to aspiration risk. It appears that the resident has been gradually declining and was "actively dying". It appears to be the natural decline of the resident. Nothing in the medical records mentions any type of malnourishment, a diagnosis of malnourishment or any concerns of this nature. It appears to be a failure to thrive, a natural ending of life. Resident was 89 years old. Based on this, this allegation is UNSUBSTANTIATED. See 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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 27-AS-20200505124837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
	VISIT DATE: 03/22/2021

NARRATIVE

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Resident has not been adequately hydrated resulting in dehydration
Medical records 5/5/20- patient is looks intravascularly dry and for that reason I will give her gentle IVF hydration with close monitoring of her volume status. Patient has had a rapid physical and cognitive decline over the last 2 months, she is non-responsive, has not had anything to eat or drink for 3 days and requires total care. Hospice RN discouraged facility staff or patient family from forcing the patient to eat or drink due to aspiration risk. It appears to be the natural decline of the resident. Nothing in the medical records mentions any diagnosis of dehydration or concerns of dehydration. It appears to be a failure to thrive, a natural ending of life. Resident was 89 years old. Based on this, this accusation is UNSUBSTANTIATED.

Insufficient staff to meet resident's needs
Complainant stated that this allegation was added because of a previous complaint that was filed and the complainant "didn't hear anything back from CCL" Complaint control # 27-AS-20200115133115, dated 1/15/20 was substantiated. A finding of substantiated for this allegation would be tantamount to double jeopardy, in which the facility is held accountable for the same violation for the exact same incident. Complainant admitted that she was not able to see her family member for 4 months, due to the pandemic and assumed from the previous pre -pandemic visits, that the facility was understaffed. Based on this, the allegation is UNSUBSTANTIATED.

As a result of this investigation, LPA finds the allegations that resident has not been adequately fed resulting in weight loss, resident has not been adequately hydrated resulting in dehydration and insufficient staff to meet resident's needs 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 the evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

LIC9099 (FAS) - (06/04)

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