347004307-10-20-2021-25-AS-LMUZ-C86RRS-20211026131535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004307
Report Date: 10/20/2021
Date Signed: 10/20/2021 01:45:04 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
10/01/2021 and conducted by Evaluator Jacob Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211001155803

FACILITY NAME:	PINE HOLLOW CARE HOME		FACILITY NUMBER:	347004307
ADMINISTRATOR:	MATSKEVICH, TATYANA		FACILITY TYPE:	740
ADDRESS:	8515 RAPOZO CT.		TELEPHONE:	(916) 628-6150
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	6	CENSUS: 4	DATE:	10/20/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Tatyana Matskevich, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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lack of care and supervision resulting in a resident sustaining an injury due to a fall

INVESTIGATION FINDINGS:

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On 10/20/2021, Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced to deliver findings for a complaint Community Care Licensing (CCL) received on 10/01/2021 which alleged that “lack of care and supervision resulting in a resident sustaining an injury due to a fall”. LPA met with Administrator Tatyana Matskevich and explained the purpose of the visit. Prior to entering, 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; contacted licensee and 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 staff and documented temperature in their visitor screening log.

CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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-20211001155803

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: PINE HOLLOW CARE HOME	FACILITY NUMBER: 347004307
	VISIT DATE: 10/20/2021

NARRATIVE

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Throughout the course of the investigation, CCL conducted interviews and reviewed documents. Interviews were conducted with residents R2-R5, Administrator, and R1’s Responsible Party (RP). Through interviews conducted, CCL learned that R1 would sometimes help himself to his room/bathroom without asking for assistance. On this day it was immediately following lunch time, and staff was working in the kitchen/dining area. R1 was sitting in front of television in living room when he decided to go to his bedroom without notifying the staff. His bedroom is around the corner from the living room, and before staff noticed he had moved, S2 heard his fall. Staff found R1 on the floor and asked him to stay on the floor while she called paramedics. Paramedics arrived shortly thereafter (within 10-20 minutes). CCL was informed that staffing was adequate the day of the fall, and R1 was regularly monitored by caretakers. CCL was unable to determine that R1’s fall was due to lack of care and supervision.

Through interviews conducted, documents reviewed, and facility visits performed; CCL finds the allegation of Facility’s lack of care and supervision resulted in resident’s fall to be UNSUBSTANTIATED. A finding that the 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. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. A copy of this report was left at facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC9099 (FAS) - (06/04)

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