097002991-6-24-2021-27-AS-LMUZ-C4HPBG-20210701111019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 06/24/2021
Date Signed: 06/24/2021 12:36:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2020 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 27-AS-20201222135504

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: 21	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Earlene Martin		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility staff did not clean resident's bathroom
Resident was left in soiled diapers
Resident was left on soiled linens
Facility staff are not adequately trained

INVESTIGATION FINDINGS:

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Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore an N-95 respirator and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Earlene Martin.

Allegations: Facility staff did not clean resident's bathroom - Resident was left in soiled diapers - Resident was left on soiled linens
The complaint lists a "Jerry" as the resident, but there has never been a "Jerry" at the facility. There is however, a "R1". Interview with staff regarding R1's room, is that it cleaned 1x a week. LPA Smith performed a visual inspection on 6/22/21 and the room was clean and tidy. The bathroom was clean. There were no odors. Well within Title 22 regulations. Staff stated that when the complaint came in, the facility was in lockdown due to a covid outbreak at the facility. Approximately, 35 residents / staff were positive for covid at that time. Meals were being served in the rooms and "normal" services were interrupted due to the quarantine lockdown.

See 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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-20201222135504

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
	VISIT DATE: 06/24/2021

NARRATIVE

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The facility had to hire emergency outside pandemic personnel due to regular staff testing positive and in quarantine. Thus, based on the fact that the complaint does not have certain identifying information, dates and pandemic quarantine rules were implemented at the time, these allegations are UNSUBSTANTIATED.

Staff not adequately trained
Medication administration is performed by Earlene Martin and she is the designated employee who preps / dispenses medication for the day. The back up person is the administrator, Joel Matkovich. Title 22, 87411 specifically states that the staff member performing a specific duty be adequately trained in that particular duty. Since witnesses will not return phone inquires, LPA cannot specifically gather more information on the allegation that staff are not adequately trained. Facility stated they have had narcotic thefts in the past and they wanted to limit the number of people who handled medications. Based on this, this allegation is UNSUBSTANTIATED.

As a result of this investigation, LPA finds the allegation that facility staff did not clean resident's bathroom, resident was left in soiled diapers, resident was left on soiled linens and facility staff are not adequately trained 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) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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