315002339-8-30-2021-25-AS-KHOS-C6FM3C-20210901091456

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002339
Report Date: 08/27/2021
Date Signed: 08/30/2021 08:29:56 AM

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
04/28/2021 and conducted by Evaluator Jacob Williams

COMPLAINT CONTROL NUMBER: 25-AS-20210428110318

FACILITY NAME:	GARDEN VILLA		FACILITY NUMBER:	315002339
ADMINISTRATOR:	KAUR, KANWALPREET		FACILITY TYPE:	740
ADDRESS:	1104 NOTTINGHAM COURT		TELEPHONE:	(916) 871-4682
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	6	CENSUS: 6	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Sonia Morrison, Caregiver		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Resident was physically abused while in care.

INVESTIGATION FINDINGS:

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On 08/27/2021 at 4:00 AM , Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced to deliver a complaint finding Community Care Licensing (CCL) received on 04/28/2021. LPA requested for Administrator, Preety Kaur to be present, but administrator was busy and could not arrive. LPA left a voice message with Administrator by phone and explained the purpose of the visit, findings, and appeal rights. LPA went over complaint findings with Caregiver. Caregiver to sign report.

Throughout the course of the complaint investigation, the Department obtained documents such as resident’s (R1) Physician’s Report, medication list, medical documents, and SOC341. LPA also interviewed Residents 1-3, Staff 1-2, and Witnesses 1-2.

********** Continue on page LIC 9099-C **************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210428110318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GARDEN VILLA	FACILITY NUMBER: 315002339
	VISIT DATE: 08/27/2021

NARRATIVE

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The event was witnessed by one individual in a room with many others present, and while majority of them did not deny that it happened, nobody else saw it happen. S1 did not deny touching R1s arm after R1 was combative and had hit S1, but denies doing it with any force. All interviews with staff and residents could not recall a time when S1 ever was forceful or acted out of line with any residents in all her time working at Garden Villa.

Through interviews and document review, there is not enough evidence to Substantiate this complaint. Therefore, the Department finds the allegations to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted. A copy this report was left at the facility. Appeal rights were given.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

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