097003566-6-26-2023-59-AS-LMUZ-CT7QXL-20230627123341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097003566
Report Date: 06/26/2023
Date Signed: 06/26/2023 11:45:36 AM

Unfounded

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
03/06/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230306163754

FACILITY NAME:	LAKE VIEW RESIDENTIAL CARE		FACILITY NUMBER:	097003566
ADMINISTRATOR:	PASHINA, ELENA		FACILITY TYPE:	740
ADDRESS:	2932 ABERDEEN LANE		TELEPHONE:	(916) 933-1230
CITY:	EL DORADO HILLS	STATE: CA	ZIP CODE:	95762
CAPACITY:	6	CENSUS: 5	DATE:	06/26/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Caregiver Anatoliy Lutsuk		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not safeguard resident's personal equipment

INVESTIGATION FINDINGS:

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

On 6/26/2023, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Caregiver Anatoliy Lutsuk.

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: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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 59-AS-20230306163754

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: LAKE VIEW RESIDENTIAL CARE	FACILITY NUMBER: 097003566
	VISIT DATE: 06/26/2023

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

Facility staff did not safeguard resident’s personal equipment.
On 5/17/22, R1 arrived at the facility. The medical supply service delivered R1’s medical equipment to the facility however on 5/18/22, R1 relocated to another licensed facility. When the medical equipment was delivered to this facility the licensee was out of town and there was some confusion on where R1’s equipment needed to be sent. On 10/27/22 the licensee and R1’s responsible party communicated with the medical supply company to ensure R1’s equipment was picked up from this facility and taken to R1’s new facility. Based on interviews conducted and records review, the licensee did safeguard resident’s medical equipment and made arrangements for R1’s medical equipment to be sent to the correct location. This agency has investigated the complaints alleging, facility staff did not safeguard resident’s personal equipment. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview with administrator. Copy of the report provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2