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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 07/01/2024
Date Signed: 07/01/2024 10:11:45 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
06/19/2024 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20240619152815
FACILITY NAME:NEW WEST HAVEN IIFACILITY NUMBER:
097002991
ADMINISTRATOR:TANIA LANGLANDFACILITY TYPE:
740
ADDRESS:2551 CAMEO DRIVETELEPHONE:
(530) 677-2979
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:67CENSUS: 39DATE:
07/01/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator Jennifer ScarberryTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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The facility refused to produce records.
INVESTIGATION FINDINGS:
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On 7/1/24 Licensing Program Analyst (LPA) Lavinia Muscan conducted an unannounced complaint visit and met with Administrator Jennifer Scarberry. It was alleged that the Licensee did not provide records to the resident or resident’s responsible party/representative. The Licensee was informed that all information and records obtained from or regarding residents shall be confidential and shall be made available upon the resident’s written consent or that of their designated representative.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided and exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20240619152815
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: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87506(c)(1)
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(c)All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by:
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The Licensee agrees to provide records immediately to resident’s representative and send proof to Community Care Licensing by POC due date 7/5/2024.
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Based on record reviewed it was determined that the Licensee did not produce records for R1 to R1’s representative. This poses a potential health and safety risk to residents in care.
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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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2