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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 236803795
Report Date: 11/27/2023
Date Signed: 11/27/2023 10:15:09 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20231115100622
FACILITY NAME:CANYON VIEW SENIOR HOME CAREFACILITY NUMBER:
236803795
ADMINISTRATOR:PRAIPHETSAK, WIROTEFACILITY TYPE:
740
ADDRESS:512 CANYON VIEW CTTELEPHONE:
(707) 463-5589
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:7CENSUS: 5DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Will PraiphetsakTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility did not conduct an assessment prior to admission
INVESTIGATION FINDINGS:
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegation. LPA met with Administrator Will Praiphetsak and reviewed records. Based on records reviewed, Licensee did not conduct a pre-placement appraisal and failed to review the medical assessment which stated resident had aggressive behaviors.
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Licensee and Appeal rights were given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20231115100622

FACILITY NAME:CANYON VIEW SENIOR HOME CAREFACILITY NUMBER:
236803795
ADMINISTRATOR:PRAIPHETSAK, WIROTEFACILITY TYPE:
740
ADDRESS:512 CANYON VIEW CTTELEPHONE:
(707) 463-5589
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:7CENSUS: 5DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Will PraiphetsakTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility abandoned resident at hospital
INVESTIGATION FINDINGS:
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5
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7
8
9
10
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12
13
At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegation. LPA met with Administrator Will Praiphetsak and reviewed records. Based on interviews conducted and a review of records, Administrator did not take resident to the hospital. A discussion was held with the responsible party and it was decided the resident needed a higher level of care than the facility could provide. Responsible party took resident to the hospital. Licensee was not aware the resident was left at the hospital.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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 3
Control Number 21-AS-20231115100622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CANYON VIEW SENIOR HOME CARE
FACILITY NUMBER: 236803795
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
87457(a)
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87457 Pre-Admission Appraisal - General:(a)Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for
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Licensee to review regulation regarding pre-Admission appraisals and reappraisals. LPA provided copies of each. Licensee to send self certification that they understand and will follow going forward.
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facility admissions. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not conduct the pre-placement appraisal. This poses a potential Health, Safety or personal rights risk to residents.
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Self certification to be sent by POC date of 12/08/2023.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3