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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097002991
Report Date: 08/05/2021
Date Signed: 08/05/2021 11:39:29 AM



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
05/07/2021 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210507131959
FACILITY NAME:NEW WEST HAVEN IIFACILITY NUMBER:
097002991
ADMINISTRATOR:JOEL MATKOVICHFACILITY TYPE:
740
ADDRESS:2551 CAMEO LANETELEPHONE:
(530) 677-2979
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:67CENSUS: 22DATE:
08/05/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sunny Matkovich, OwnerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner.
Staff did not notify authorized representative in change of health conditions.
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Thursday August 5, 2021 to conclude a complaint investigation regarding the above allegations. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.
Throughout the course of the investigation, the Department interviewed R1's Power of Attorney and family, assigned hospital physician, care staff, clients in care, and facility Administrator. Additionally, the Department reviewed staffing schedules, employee roster, R1's service plan, physicians report, resident notes, admission agreement, resident profile, and incident reports. The Department learned that R1 had a fall on 4/27/2021 and
(continued on 9099-C)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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 5
Control Number 25-AS-20210507131959
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: 08/05/2021
NARRATIVE
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was in pain after. The facility did not seek treatment for the fall and subsequent pain. On 5/3/2021, interviews revealed that R1's leg was warm to the touch, purple, and swollen. The facility did not inform R1's POA about the fall and pain until she was sent to the hospital on 5/3/2021.

As a result of this investigation, the Department finds the allegations to be Substantiated.
A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights and a copy of this report was given to Sunny Matkovich.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/07/2021 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210507131959

FACILITY NAME:NEW WEST HAVEN IIFACILITY NUMBER:
097002991
ADMINISTRATOR:JOEL MATKOVICHFACILITY TYPE:
740
ADDRESS:2551 CAMEO LANETELEPHONE:
(530) 677-2979
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:67CENSUS: 22DATE:
08/05/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sunny MatkovichTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Resident fell while in care resulting in fracture.
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Thursday August 5, 2021 to conclude a complaint investigation regarding the above allegation. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.
Throughout the course of the investigation, the Department interviewed R1's Power of Attorney and family, assigned hospital physician, care staff, clients in care, and facility Administrator. Additionally, the Department reviewed staffing schedules employee roster, R1's service plan, physicians report, resident notes, admission agreement, resident profile, and incident reports. The Department learned that while R1 did have a fall which
(continued on 9099-c)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20210507131959
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: 08/05/2021
NARRATIVE
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resulted in a fracture, it was not able to be determined that this was due to neglect or lack of supervision from staff. Due to this information the preponderance of evidence standard has not been met, therefore the above allegation is determined to be UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20210507131959
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited
CCR
87465(g)
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87465Incidental Medical & Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health . . .
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Licensee to submit scheduled date of training for all staff regarding when to call 911 and emergency procedures.
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This requirement was not met as evidenced by R1 sustaining a fall and the facility failing to seek medical attention.
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Type B
08/20/2021
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities
(8) To have their representatives regularly informed by the licensee of activities related to care or services . . . This requirement was not met as
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Licensee to submit scheduled date of training for all staff regarding who to call after a resident's fall or change of condition.
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evidenced by R1 sustaining a fall which was not reported to R1's POA until R1 was sent out via 911 days later.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5