347003843-8-21-2021-25-AS-KHOS-C67MXD-20210824095945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003843
Report Date: 08/21/2021
Date Signed: 08/21/2021 10:17:24 AM

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
04/09/2021 and conducted by Evaluator Melana Llopis

COMPLAINT CONTROL NUMBER: 25-AS-20210409105647

FACILITY NAME:	NORTH AVENUE VILLA		FACILITY NUMBER:	347003843
ADMINISTRATOR:	ADRIAN BERCI		FACILITY TYPE:	740
ADDRESS:	5216 NORTH AVENUE		TELEPHONE:	(916) 705-3729
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	08/21/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Nora Berci		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of staff to meet resident needs
Facility is dirty
Residents bathroom is dirty
Staff is not following resident's diabetic diet
Resident does not have a trash can in the bathroom

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannouncd on 08/21/2021 to deliver complaint findings for a complaint the Department received on 4/9/2021. LPA met with Administrator, Nora Berci and explained the purpose of the visit. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; upon entering LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Kathleen Louis, staff, upon entering the facility.

Throughout the course of the investigation, LPA conducted multiple interviews, inspected the facility and reviewed documents pertinant to the investigation.

Results are as follows:
***Continuation on LIC9099-C***

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2021

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 3

Control Number 25-AS-20210409105647

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: NORTH AVENUE VILLA	FACILITY NUMBER: 347003843
	VISIT DATE: 08/21/2021

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

Allegation: Lack of staff to meet resident needs
Complaint alleged the facility staff were not showering resident (R1), meeting their dietary needs and were not cleaning R1's bathroom and bedroom. LPA virtually toured the facility on 4/16/2021 and spoke with R1. LPA observed the facility and R1's room to be uncluttered and in good repair. R1 stated they are happy with their care and their room is kept clean and the facility provides them with adequate meals. LPA spoke with R1's brother on 05/03/2021 who stated the facility is doing a good job with caring for their sister. R1's brother stated they are satisfied with R1's care at the facility. Allegation is UNFOUNDED.

Allegation: Facility is dirty
The complaint alleged the facility is not keeping resident (R1)'s room tidy and clean. LPA contacted the facility on 04/16/2021 and conducted a virtual tour of the facility due to Covid-19 and precautionary measures at time of contact. LPA observed R1's room to be uncluttered and in good repair. LPA spoke with R1 who stated their room is cleaned daily and their floors are swept weekly. R1 stated their trash is taken out daily as well. R1 stated they did not have any issues with their care. On 05/03/2021, LPA spoke with R1's representative who also stated they are satisfied with R1's care and did not have issues with R1's room being dirty. Allegation is UNFOUNDED.

Allegation: Residents bathroom is dirty
The complaint alleged the facility is not cleaning R1's bathroom. LPA contacted the facility on 04/16/2021 and conducted a virtual tour of the facility due to Covid-19 and precautionary measures at time of contact. LPA observed R1's bathroom to be uncluttered and in good repair. LPA spoke with R1 who stated their room is cleaned daily and their floors are swept weekly. R1 stated their trash is taken out daily as well. R1 stated they did not have any issues with their care. LPA spoke with R1's representative on 05/03/2021 who also stated they are satisfied with R1's care and did not have issues with R1's bathroom being dirty. Allegation is UNFOUNDED.

***Continuation on LIC9099-C***

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20210409105647

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: NORTH AVENUE VILLA	FACILITY NUMBER: 347003843
	VISIT DATE: 08/21/2021

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

Allegation: Staff is not following resident's diabetic diet
The complaint alleged the facility is not providing R1 with adequate meals to meet their diabetic diet. LPA spoke with Administrator and resident (R1) on 04/16/2021. Administrator and R1 stated R1 is diabetic. R1 stated they do not eat things such as "noodles or spaghetti." R1 stated the facility will provide R1 with other alternatives such as a "chef's salad," and sugar-free deserts. R1 stated they do not have issues with the meals being provided. Allegation is UNFOUNDED.

Allegation Resident does not have a trash can in the bathroom
The complaint alleged the facility did not have a trash can in resident (R1)'s bathroom. LPA spoke with resident (R1) on 04/16/2021. R1 stated there is a trash can in their restroom. On 05/03/2021 LPA spoke with R1's representative who stated there is a trash can in R1's bathroom that was provided by the facility. Allegation is UNFOUNDED.

Due to the above information, LPA finds the allegations to be UNFOUNDED, meaning that the allegations are false, could not have happened, and/or are without a reasonable basis.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3