097003566-10-30-2023-59-AS-LMUZ-CXCQ6U-20231107105403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097003566
Report Date: 10/30/2023
Date Signed: 10/30/2023 12:34:49 PM

Unsubstantiated

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
09/29/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230929120553

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: 6	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Caregiver Oksana Gutsu		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff over medicated resident in care.

INVESTIGATION FINDINGS:

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On 10/30/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Caregiver Oksana Gutsu. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: Staff over medicated resident in care.
Based on documents obtained and statements received, the department determined that there was insufficient evidence that any resident was overmedicated. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Interviews indicated that staff were not overmedicating the residents and residents expressed no concerns with medication administration. Based upon the information obtained during investigation, the above allegation is 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.
Exit interview was conducted with Caregiver and a copy of this report was provided to the facility.

Unsubstantiated

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: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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 4

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
09/29/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230929120553

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: 6	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Caregiver Oksana Gutsu		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff allowed resident to push another resident in care.
Staff allowed resident to yell at another resident in care.
Staff is not able to care and supervise residents due to inadequate staffing.
Staff did not ensure resident's dietry needs were met.
Staff did not provide authorized representative an admissions agreement during preadmissions.
Staff do not provide daily activities for residents in care.
Staff does not ensure residents' room are clean and sanitized.
Facility backyard is not appropriately equipped for outdoor use.
Staff locked resident in bedroom.
Staff do not dispose residents' urine in commode.
Staff did not ensure resident's hygiene needs were being met.

INVESTIGATION FINDINGS:

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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: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20230929120553

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: 10/30/2023

NARRATIVE

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Staff allowed resident to push another resident in care.
Staff allowed resident to yell at another resident in care.
Based on interviews with staff and residents, the department determined that there was no one yelling or pushing residents in care therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff is not able to care and supervise residents due to inadequate staffing.
LPA has reviewed the facility schedule and observed that day shifts are covered by multiple staff. There is no evidence to support the allegation that needs are not being met due to staffing. LPA learned that there are at least 2 direct care staff available during the day. Residents indicated they feel that their needs are met, and LPA finds no evidence that the current staff level is insufficient. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff did not ensure resident's dietary needs were met.
Department conducted interviews with residents and staff to investigate this allegation. Interviews indicated that residents were happy with dietary services at facility and did not indicate any issues. Based on the record review for R1’s physician's reports and review of preadmission records, there are no dietary restrictions for R1, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff did not provide authorized representative an admissions agreement during preadmissions.
Based on records reviewed and interviews conducted, R1s responsible party did receive an Admission Agreement for R1 as required. From record review, the department observed a signed contract between the responsible party and the facility. Furthermore, the Licensee sent proof of sending the Admission Agreement to the RP twice, after it was handed to RP when signed, therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20230929120553

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: 10/30/2023

NARRATIVE

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Staff do not provide daily activities for residents in care.
Based on interviews the facility does their best to accommodate each resident. Staff will have exercise sessions with the residents, the residents go on walks and the facility has books or arts for residents who enjoy reading or like arts and crafts. Additionally, residents' interviews did not indicate any problems with daily activities at the facility, therefore concluded that the residents can also watch TV if they choose, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff does not ensure residents' room are clean and sanitized.
Facility backyard is not appropriately equipped for outdoor use.
Staff locked resident in bedroom.
Staff do not dispose residents' urine in commode.
Staff did not ensure resident's hygiene needs were being met.
Based on interviews and observation, the department observed the facility to be well equipped for outdoor use. The facility has outdoor benches and a patio in the backyard. LPA toured the facility on 10/4/23 and did not find any dirty bedding, smells, or dirty rooms. Residents stated the caregivers clean the facility and take out trash frequently. It was observed that none of the commodes had any urine in them and that the commodes were clean and sanitized. It was also observed that none of the resident doors had any form of locking device on them. Additionally, staff and residents' interviews did not indicate any issues at the facility with cleanliness, sanitation, usage of outdoor/backyard areas, toilets, rooms, commodes and other area and found out that staff were assisting with resident's care needs per their service and care plans. Based on all this information, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview was conducted with Caregiver and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4