572700714-12-15-2023-21-AS-VBEI-CZDVH5-20240111152633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 572700714
Report Date: 12/15/2023
Date Signed: 12/15/2023 10:39:48 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2023 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20231011134607

FACILITY NAME:	CAREWELL AT PISTACHIO LLC		FACILITY NUMBER:	572700714
ADMINISTRATOR:	PANTIG, PAULIN		FACILITY TYPE:	740
ADDRESS:	1125 PISTACHIO COURT		TELEPHONE:	(530) 759-2060
CITY:	DAVIS	STATE: CA	ZIP CODE:	95618
CAPACITY:	6	CENSUS: 6	DATE:	12/15/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Kirk Lisondra, Lead Care Staff		TIME COMPLETED:	09:57 AM

ALLEGATION(S):

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Personal Rights
Staff did not provide continence care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the complaint investigation and deliver findings for the allegations listed above. LPA met with lead care staff Kirk Lisondra. House Manager Paulin Pantig was contacted by phone. There were 6 residents and 3 care staff on site at the time of inspection.

LPA conducted interviews, made observations, reviewed documents and made the following determinations:

Continued on 9099-C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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 21-AS-20231011134607

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CAREWELL AT PISTACHIO LLC	FACILITY NUMBER: 572700714
	VISIT DATE: 12/15/2023

NARRATIVE

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.....Continued from 9099

A review of the ADL (Activities of Daily Living) records indicate that Resident (R1) was helped six times on June 14, 2023 to use the commode and have dignity brief changed by the staff on duty. ADL care notes state that R1 rang service bell multiple times for continence care and staff responded. S1 stated that they did not recall any concerns on that day other than R1 feeling constipated. ADL records for June 14, 2023 indicate R1 called 911 two times independently during the daytime hours but was not transported by emergency medical responders. A review of records from Davis Fire Department state that R1 was assessed, staff was questioned and R1 was released to facility’s care. R1 called 911 again at approximately 7 PM on June 14, 2023. R1 was transported and returned to the facility within a few hours. LPA attempted to interview R1 but R1 declined. After a review of records and interviews conducted, the allegations that staff kept R1 from using the commode and personal rights are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations areunsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC9099 (FAS) - (06/04)

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