342700946-6-12-2023-59-AS-LMUZ-CSR2JQ-20230612172643

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700946
Report Date: 06/12/2023
Date Signed: 06/12/2023 12:10:03 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2023 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20230602164909

FACILITY NAME:	BELHAVEN ESTATE II		FACILITY NUMBER:	342700946
ADMINISTRATOR:	BROOKS, DANIEL		FACILITY TYPE:	740
ADDRESS:	9046 ELM AVE		TELEPHONE:	(831) 801-4626
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	6	CENSUS: 6	DATE:	06/12/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	House Manager, Kaylee Moss		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff not properly storing medications.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 06/12/23 to do complaint investigation for above allegation. LPA met with House Manager, Kaylee Moss and explained the purpose of the visit.

The department did facility record review, facility tour and staff interviews for complaint investigation.

***report continue on LIC9099C.......

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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 59-AS-20230602164909

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BELHAVEN ESTATE II	FACILITY NUMBER: 342700946
	VISIT DATE: 06/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

**** report continued from LIC9099C......

Allegation ---Facility staff not properly storing medications.

During the complaint investigation, LPA interviewed 2 staff and conducted a walk thru of the facility on 06/12/23 . During the walk thru no medications were observed to be on the floor or any other area other than the medication room in a locked cabinet. Interviews indicated that staff were not leaving and medications anywhere but only in the medication room, which is inaccessible to residents. This agency has investigated the complaint alleging "facility staff not properly storing medications" and found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Based on this investigation, no deficiencies are cited.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2