Community Care Licensing

SUPERVISOR'S NAME: Laura Munoz TELEPHONE: (916) 263-4743 LICENSING EVALUATOR NAME: Michael Smith TELEPHONE: (916) 208-7807 LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021

Document Has Been Signed on 10/08/2021 08:47 AM - It Cannot Be Edited

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 09/16/2021 Section Cited	1 2 3 4 5 6 7	87355- Criminal Record Clearance- The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence or presence in the facility, based upon the results of such review. This requirement is
	8 9 10 11 12 13 14	not met as evidenced by: Based on the investigation, staff members, 1) Ashley Kelly 2) Olga Estrada 3) Kitty Flannagan and 4) Joshua Sullivan were present and working in the facility without being criminally cleared. Licensee did not have the above referenced individuals criminally cleared prior to being present in the facility. This is in violation of this section. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Request Denied Type A 09/16/2021 Section Cited	1 2 3 4 5 6 7	87207-False Claims-No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on investigation, staff member Sunnybrook Matkovich, submitted a
	8 9 10 11 12 13 14	back dated UIR and lied to the department's investigator about the actual date of submission. This is in violation of this section. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Laura Munoz TELEPHONE: (916) 263-4743 LICENSING EVALUATOR NAME: Michael Smith TELEPHONE: (916) 208-7807 LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021

Document Has Been Signed on 10/08/2021 08:47 AM - It Cannot Be Edited

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2021 Section Cited	1 2 3 4 5 6 7	87211-Reporting Requirements-A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as
	8 9 10 11 12 13 14	evidenced by: Based on the investigation, facility failed to report an incident where R1 sustained a fractured hip. Licensee is in violation of this section. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 09/16/2021 Section Cited	1 2 3 4 5 6 7	Administrator - Qualifications and Duties - The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on witness statements and investigation, administrator Joel Matkovich, is not physically present in the facility to adequately manage the facility and is in violation of this section. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Laura Munoz TELEPHONE: (916) 263-4743 LICENSING EVALUATOR NAME: Michael Smith TELEPHONE: (916) 208-7807 LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021

Document Has Been Signed on 10/08/2021 08:47 AM - It Cannot Be Edited

FACILITY NAME: NEW WEST HAVEN II	FACILITY NUMBER: 097002991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 09/16/2021 Section Cited	1 2 3 4 5 6 7	87761- Penalties- This requirement is not met as evidenced by: Based on the investigation, R1s injuries and the failure to report the injuries mandates the requirement of an enhanced civil penalties. This poses an immediate health and safety risk to residents in care.
Request Denied Type B 09/16/2021 Section Cited	1 2 3 4 5 6 7	87755-Inspection Authority of the Licensing Agency-The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. This requirement is not met as evidenced by: Based on the
	8 9 10 11 12 13 14	investigation and witness statements ,facility failed to furnish requested records by a duly authorized representative of the department. Licensee did not furnish requested records and is in violation of this section. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
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SUPERVISOR'S NAME: Laura Munoz TELEPHONE: (916) 263-4743 LICENSING EVALUATOR NAME: Michael Smith TELEPHONE: (916) 208-7807 LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021