342700947-6-12-2023-59-AS-LMUZ-CSR2JC-20230612172608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700947
Report Date: 06/12/2023
Date Signed: 06/12/2023 12:06:21 PM

Unsubstantiated

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-20230602164531

FACILITY NAME:	BELHAVEN ESTATE		FACILITY NUMBER:	342700947
ADMINISTRATOR:	WILSON, JENNIFER		FACILITY TYPE:	740
ADDRESS:	9048 ELM AVE		TELEPHONE:	(831) 801-4626
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	6	CENSUS: 6	DATE:	06/12/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	House Manager, Kaylee Moss		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are not properly transferring resident.
Resident left in soiled diaper for extended amount of time.

INVESTIGATION FINDINGS:

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

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

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

Unsubstantiated

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)

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Control Number 59-AS-20230602164531

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	FACILITY NUMBER: 342700947
	VISIT DATE: 06/12/2023

NARRATIVE

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****continued from LIC9099....................

Allegation- Staff are not properly transferring resident.

Department interviewed 2 staff and 2 residents during complaint investigation .Department has reviewed facility records, including charting notes, staff schedule and resident records. Interviews and record review indicated that facility was following resident's physician's orders while transferring them. Residents and staff interview indicated that facility has all transferring equipment's such as hoyer lift, sit to stand lift to transfer residents and all equipment's were in good working condition without any issues. Furthermore, staff get proper training in timely manner regarding safe transfer techniques for residents and can ask any questions from management in case they have any questions or issues to address in this area, therefore, the above allegation is found to be UNSUBSTANTIATED.

Allegation- Resident left in soiled diaper for extended amount of time.

Department interviewed 2 staff and 2 residents during complaint investigation. Department has reviewed facility records, including charting notes, staff schedule and resident records. Interviews and record review indicated that resident’s ADL’s which includes residents showering, incontinence and care needs are met as required and documented accordingly. Residents’ interviews indicated that staff were providing care in a professional manner and did not express any concerns. The department conducted interviews, facility observation and record review to investigate above allegation. During interviews with facility staff and residents, it has been revealed that facility is providing care to residents according to resident’s needs and service plans. During residents’ and staff interviews, it has been concluded that facility has enough staff to meet the needs of the residents in care. During department visits, department observed that residents appeared to be well groomed and in good care, therefore, the above allegation is found to be UNSUBSTANTIATED.
A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
No citations were issued today. Exit meeting conducted with house manager.
A copy of this report has been provided to facility.

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)

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