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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 572700714
Report Date: 12/23/2021
Date Signed: 12/23/2021 10:05:07 AM

Unsubstantiated


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
10/19/2021 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20211019122728
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: DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Paulin Pantig, Administrator (via phone) and Benjie Pulan, Care StaffTIME COMPLETED:
10:05 AM
ALLEGATION(S):
1
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9
Facility did not meet resident's nutritional needs
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Jill Nakagawa conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Benjie Pulan, Care Staff with Paulin Pantig, Administrator (via phone). It is alleged facility is not meeting the resident’s nutritional needs. During the investigation LPA reviewed records, made observations at the facility on 3 separate occasions (10/21/2021, 10/29/2021, 11/03/2021) and conducted interviews and obtained photos.
At today’s inspection, LPA observed that the facility was well-stocked and had a two day supply of perishable foods (including watermelon, pineapple, apaplesauce, juices) and a seven day supply of non-perishable foods as required in regulation Title 22, Division 6, Chapter 8, Article 10, Food Services. LPA observed food stores on several visits on different days of the week, and found supplies were within regulation. Although the allegation may have happened, or is true, there is not a preponderance of evidence to prove the allegation is true or did, or did not, happen. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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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