315002837-11-30-2023-59-AS-KHOS-CYAQ3B-20231207104827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002837
Report Date: 11/30/2023
Date Signed: 11/30/2023 09:19:15 AM

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
07/20/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230720132814

FACILITY NAME:	CROWN POINT VILLA		FACILITY NUMBER:	315002837
ADMINISTRATOR:	MUBEEZI, VIOLET		FACILITY TYPE:	740
ADDRESS:	1001 TAMARACK COURT		TELEPHONE:	(301) 541-4028
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	6	CENSUS: 6	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator: Violet Mubeezu		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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- Staff not allowing resident to have visitors at facility.
- Staff not communicating with responsible party about resident's care.

INVESTIGATION FINDINGS:

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On 11/30/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 7/20/2023. LPA met with administrator, Violet Mubeezi, and explained the purpose of the visit.

During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, admission agreement, preplacement appraisal, and appraisal/needs and services plan.

Continue on page LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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 59-AS-20230720132814

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: CROWN POINT VILLA	FACILITY NUMBER: 315002837
	VISIT DATE: 11/30/2023

NARRATIVE

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Allegation: Staff not allowing resident to have visitors at facility. – Unsubstantiated.

According to an interview conducted, on 7/20/2023 at approximately 12:45 PM, R1’s responsible party (RP) was refused entry into the facility and was asked by the facility’s administrator to leave the facility. The Department received an interview statement from R1’s RP. RP stated arrived at the facility during lunch time and was refused visitation. RP requested to wait in R1’s bedroom until lunch was over. Administrator refused and asked RP to leave. RP stated R1’s family member was there to observe the incident.

The Department reviewed R1’s admission agreement. According to the admission agreement, the agreement must include the facility policy concerning family visits and communication. The policy must be designed to encourage regular family involvement with the resident. The policy must also provide ample opportunity for family participation in facility activities. Facility visiting hours are 9 AM to 4 PM.

The Department received interview statements from a total of three (3) facility staff (S). Interview statement received from S1 stated, visitation hours are from 8 AM to 4 PM. Visitors are welcome at the facility during visitation hours. Staff are not allowed to turn visitors away. Interview statement received from S2 indicated, there is a visitation policy that the residents’ family members agreed upon which is to visit residents before or after lunch. This is due to residents not wanting to eat when visitors are around. S2 stated R1’s RP comes to the facility everyday to visit R1. RP came during lunch time and administrator requested for RP to come visit before lunch time. RP was waiting in R1’s bedroom while residents were finishing their meals. Interview statements received from the facility’s administrator indicated that R1’s RP visited the facility every day. RP would stand at the table for most of the meals and make comments and give instructions to other residents on what they should eat first. According to the administrator, RP was being disruptive. A resident (R2) made complaints about RP’s presence at the facility during mealtimes. RP had showed up to the facility with different agents at mealtimes during lunchtime.

The Department received an interview statement from R1’s family member (FM). Interview statement received from FM indicated that RP and FM arrived at the facility to visit R1 during lunch time and were refused entry into the facility. Administrator told RP and FM that the facility was audited, and they cannot have people here at the facility while residents are having their lunch. The administrator then proceeded to notify RP and FM that an email was sent indicating the facility is not allowing visitors.

The Department is unable to determine if facility staff are not allowing residents to have visitors at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230720132814

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: CROWN POINT VILLA	FACILITY NUMBER: 315002837
	VISIT DATE: 11/30/2023

NARRATIVE

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Allegation: Staff not communicating with responsible party about resident's care. – Unsubstantiated.

According to an interview conducted, R1’s RP asked administrator what R1 had for lunch and was told R1 had eaten a taco. R1 was unable to remember what R1 ate due to dementia. Due to RP asking questions about R1’s lunch administrator told RP, “I am restricting your hours.” RP indicated that RP should be allowed to ask questions related to R1’s care e.g., what R1 ate for lunch.

The Department reviewed R1’s physician’s report. According to physician’s report, R1 has mild cognitive impairment and Type II Diabetes. According to R1’s appraisal, R1 can feed self but sometimes needs assistance. R1 is on a pre-diabetic diet.

Interview statement received from administrator indicated, administrator denied restricting visitation hours and did provide RP when asked about the food being provided to R1.

Due to the information above, CCL finds the allegations to be UNSUBSTANTIATED, meaning 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.

An exit interview was conducted, and a copy of the report was left at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

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