097002991-7-8-2021-27-AS-LMUZ-C4VPEX-20210713111553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 07/08/2021
Date Signed: 07/08/2021 01:48:37 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
01/04/2021 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 27-AS-20210104114931

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:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Ashley Kelley		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's suffered multiple falls while in care.
Medications are not labeled.
Staff not administering medications in a timely manner.
Resident's developed a pressure injury while in care.
Staff not administering medications to resident's.
Staff denied resident food.
Inadequate staffing to meet the needs of the resident's.
Staff did not ensure resident's are eating.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 Ashley Kelley.

LPA attempted to contact witnesses on multiple occasions and was unsuccessful. The complaint is completely devoid of any identifying information, resident names, staff names, dates of occurrences and witness names. Due to the generalized nature of the allegations it is impossible to narrow the focus of the investigation. Based on this, these allegations are UNSUBSTANTIATED.

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: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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 27-AS-20210104114931

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: 07/08/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

As a result of this investigation, LPA finds the allegation that resident's suffered multiple falls while in care, medications are not labeled, staff not administering medications in a timely manner, resident's developed a pressure injury while in care, staff not administering medications to residents, staff denied resident food, Inadequate staffing to meet the needs of the resident's and staff did not ensure resident's are eating 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 violations occurred.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2