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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 572700714
Report Date: 08/04/2021
Date Signed: 08/04/2021 04:01:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2021 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210317161820
FACILITY NAME:CAREWELL AT PISTACHIO LLCFACILITY NUMBER:
572700714
ADMINISTRATOR:PANTIG, PAULINFACILITY TYPE:
740
ADDRESS:1125 PISTACHIO COURTTELEPHONE:
(530) 759-2060
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:6CENSUS: 5DATE:
08/04/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Grace RaneTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Neglect/Lack of Supervision staff failed to seek timely medical attention for resident in care.
INVESTIGATION FINDINGS:
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At approximately 12:30PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility to deliver findings from an investigation conducted by the department into the above allegation. LPA was met by caregiver and screened upon entry. Based on interviews conducted and a review of records the above allegation is found to be Substantiated. Licensee did not ensure medical attention was sought in a timely manner. A fall occurred between approximately 7:30AM and 8AM on 3/16/2021, resulting in an injury to a resident. Emergency medical personnel were not contacted until 9:41AM, approximately 2 hours after the fall occurred.
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights were given. Due to technical issues, a paper copy was not provided. A copy of this report was emailed to Licensee.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2021 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210317161820

FACILITY NAME:CAREWELL AT PISTACHIO LLCFACILITY NUMBER:
572700714
ADMINISTRATOR:PANTIG, PAULINFACILITY TYPE:
740
ADDRESS:1125 PISTACHIO COURTTELEPHONE:
(530) 759-2060
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:6CENSUS: 5DATE:
08/04/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Grace RaneTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Facility staff violated personal right of resident in care and causing injuries.
Neglect/Lack of Supervision by staff resulted in resident sustaining unwitnessed fall which resulted in hospitalization.
Walker was being taken away from resident in care.
Resident's records were not kept up to date.
Staff not administering medications to resident according to physician's orders.
INVESTIGATION FINDINGS:
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At approximately 12:30PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility to conduct an investigation into the above allegations. LPA was met by Caregiver. LPA toured the facility, reviewed records and interviewed staff. Based on a record review, interviews conducted and a visual inspection on the facility, the above allegations are found to be Unsubstantiated. There was no evidence to support the allegation that staff violated residents personal rights and caused injury. Interviews conducted did not produce evidence that staff failed to supervise residents that resulted in a resident to fall. Records reviewed did not indicate any resident that required constant supervision. Based on interviews conducted, there was no indication that a residents walker was being taken away from a resident. Based on visual observation, LPA observed a walker within reach of residents able to utilize a walker. At approximately 12:45PM, LPA reviewed 5 of 5 current resident records and 8 former resident records. Continued on LIC809-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20210317161820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CAREWELL AT PISTACHIO LLC
FACILITY NUMBER: 572700714
VISIT DATE: 08/04/2021
NARRATIVE
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LPA observed the records contained the required documentation. Physician reports were current for residents with Dementia and were within regulation. LPA found resident appraisals that were 3 months past due in 3 resident files. Admission agreements were all signed by responsible parties and facility representative. LPA reviewed medication records and found centrally stored medication records matched physician orders. Facility utilizes a computerized medication administration record (MAR), and the record indicated the medications were given as ordered.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Due to technical issues, a paper copy was not provided. A copy of this report was emailed to Licensee.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20210317161820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CAREWELL AT PISTACHIO LLC
FACILITY NUMBER: 572700714
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2021
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care Services. 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health... apparent
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Licensee agrees to submit updated procedures for medical emergencies stating how they will ensure the health and safety of residents in the case of an imminent health risk by POC due date of 08/05/2021.
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life-threatening medical crisis. This requirement is not met as evividenced by: Based on interviews conducted, Licensee did not seek emergency medical care in a timely manner. This poses an Immediate risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5