<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312701038
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:22:40 PM



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
11/05/2021 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20211105063835
FACILITY NAME:MISTY WOOD SENIOR CARE LLCFACILITY NUMBER:
312701038
ADMINISTRATOR:IANCU, MARINAFACILITY TYPE:
740
ADDRESS:1626 MISTY WOOD DRTELEPHONE:
(916) 889-2039
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marina IancuTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal Eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced on 03/10/2022 to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility.

LPA investigation the allegation "Illegal Eviction.” LPA interviewed Licensees, former resident's responsible party, and a third party. Licensee did request permission to issue a 3 day eviction notice from Community Care Licensing Division that was not granted and LPA confirmed that it was not issued. Licensee was also in the process of writing a 30 day eviction notice that was not issued. The allegation is dealing whether a verbal eviction notice was given or not. Licensee stated she thinks a third party told the responsible party there is an eviction notice given. Other interviews stated there was an eviction notice given. LPA cannot prove or disproveif a verbal eviction was issued based on the different version of events. Allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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
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
11/05/2021 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20211105063835

FACILITY NAME:MISTY WOOD SENIOR CARE LLCFACILITY NUMBER:
312701038
ADMINISTRATOR:IANCU, MARINAFACILITY TYPE:
740
ADDRESS:1626 MISTY WOOD DRTELEPHONE:
(916) 889-2039
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marina IancuTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication not prescribed are being administered
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced on 03/10/2022 to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility.
LPA Hiratsuka, reviewed the resident's file and interviewed responsible parties and facility staff. There were medications with no written prescriptions brought to the facility from the responsible party that was not given to the resident. Licensee stated she locked them up immediately and asked for written prescriptions. There was also another medication that was prescribed by a nurse practitioner that the responsible party stated they did not know who that person was. LPA obtained documentation from the facility signed by the responsible party giving consent for this nurse practitioner to take over the care of the resident while this person was at this facility. The nurse practitioner prescribed the medication.
“This agency has investigated the complaint alleging; Medication not prescribed are being administered. 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."
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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 2