342700187-11-10-2021-25-AS-APEZ-C9H28J-20211207161021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700187
Report Date: 11/10/2021
Date Signed: 11/10/2021 12:28:59 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
10/19/2021 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20211019150232

FACILITY NAME:	ALL SEASONS PHEASANT RIDGE		FACILITY NUMBER:	342700187
ADMINISTRATOR:	MOLITVENIK, ANATOLIY		FACILITY TYPE:	740
ADDRESS:	8556 PHEASANT RIDGE LANE		TELEPHONE:	(916) 776-6665
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	6	CENSUS: 6	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Mariah Alcala, Caregiver		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility staff not wearing a mask as per public health order.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Michael Hood and Angela Hood arrived at the facility and met with caregivers to deliver findings into the above complaint allegation. Administrator stated that caregiver can sign report during today's visit. Facility currently does not have any COVID-19 positive cases. LPAs wore N-95 masks and were screened by facility upon entry. Facility staff wore masks in the care home.

During the investigation, LPAs toured the facility and interviewed facility staff and residents.

Interviews conducted by LPA with staff members (S1, S2, S3), residents (R1, R2, R3), and Administrator indicated that staff have not been observed inside of the facility without wearing a face mask. LPA observed video surveillance footage inside of the facility which showed staff wearing face masks while inside of the facility.

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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-20211019150232

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: ALL SEASONS PHEASANT RIDGE	FACILITY NUMBER: 342700187
	VISIT DATE: 11/10/2021

NARRATIVE

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During visits conducted on 10/28/2021 and 11/10/2021, LPAs observed that all staff were wearing a face mask while inside the facility.

Based on interviews conducted by LPAs, observations during inspection, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

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