097002991-7-3-2024-59-AS-LMUZ-D74U4X-20240712151554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 07/03/2024
Date Signed: 07/03/2024 11:11:11 AM

Unsubstantiated

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
02/08/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20240208085807

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: 38	DATE:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator Jennifer Scarberry		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Staff allowed resident in care to leave the facility unassisted

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lavinia Muscan arrived unannounced to deliver findings for allegation listed above. LPA met with Administrator, Jennifer Scarberry during today's inspection. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.
The results of the investigation are as follows:

Based on record review and staff (6) interviews it was determined that residents do not leave the facility unassisted. Staff follow behind and try to redirect residents back to the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation UNSUBSTATIATED.

Exit interview conducted and copy of this report left at facility.

Unsubstantiated

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: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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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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
02/08/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20240208085807

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: 38	DATE:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator Jennifer Scarberry		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Facility not following Stipulation requirements
Facility gate is in disrepair
Staff did not ensure resident's room is kept free of mold

INVESTIGATION FINDINGS:

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On 7/3/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to 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**

Unfounded

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: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240208085807

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: 07/03/2024

NARRATIVE

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Facility not following Stipulation requirements
Based on record reviewed and interviews it was determined that staff schedules and timesheets match the requirement of the facility stipulation at this time therefore, the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Facility gate is in disrepair
Based on record reviewed and interviews the department found that the alarm on the gate was not working, however the gate was working. The alarm broke 11/28/23, parts arrived 12/8/23, alarm was fixed 12/9/23. The gate was not observed to be in disrepair on 2/14/24/ or 6/13/24; therefore, the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff did not ensure resident's room is kept free of mold
Based on record reviewed and interviews it was determined that the facility used to have mold in a bedroom, but that bedroom was not used by any resident. The bedroom was not a staff or resident room. The facility is an older facility and when there is more rain fall the rain sometimes enters inside that room. At the time of department walk thru on 2/14/24 and 6/13/24 there was no mold noticed in the bedroom or in the facility, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and copy of this report was left at the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

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