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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002796
Report Date: 10/28/2021
Date Signed: 10/28/2021 12:37:51 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
10/21/2021 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 25-AS-20211021094346
FACILITY NAME:SWAN LAKE VILLAFACILITY NUMBER:
315002796
ADMINISTRATOR:MAKANONENG, ANDREWFACILITY TYPE:
740
ADDRESS:9702 SWAN LAKE DRTELEPHONE:
(916) 797-8521
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:7CENSUS: 6DATE:
10/28/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Andrew MakanonengTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility accepted a resident with a gastronomy tube.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/28/2021 LPA traveled to the facility to complete the complaint. LPA was screened by the Administrator at the door, temperature taken, etc. The facility has no known COVID cases at this time.
LPA has met with the Administrator and reviewed records for resident R1. It was found that the facility did accept Resident R1 on 10/13/2021 with a Prohibited Health Condition. The Administrator had attempted to contact CCL to discuss an exception, but did not make contact with anyone. At this point, there is not an exception in place for R1. The Administrator had submitted part of the exception request, but did not have all needed documents. Documents were given to LPA at the visit today.
Through interview and review of records, LPA determined that the allegation is SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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 25-AS-20211021094346
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: SWAN LAKE VILLA
FACILITY NUMBER: 315002796
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2021
Section Cited
CCR
87615(a)(2)
1
2
3
4
5
6
7
Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Gastrostomy tubes.
The facility accepted resident R1 with a gastrostomy tube.
1
2
3
4
5
6
7
The facility will submit a request for an exception to Title 22 Section 87615 (a)(2)
The facility has already submitted an exception request to CCL on this date 10/28/2021.
8
9
10
11
12
13
14
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2