Complaint Investigation Report

019200687-10-12-2022-15-AS-KHOS-CKBN7D-20221018101235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1515 CLAY STREET, STE. 310

This is an official report of an unannounced visit/investigation of a complaint received in our office on

10/21/2020 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20201021093831

Facility staff failed to accord dignity to resident in care

On 10/12/2022 starting at 10:45 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Samuel Tet, administrator and explained the purpose of the visit.

During the course of investigation, LPA obtained information, collected documents; staff roster, resident roster, R1’s physicians report, R1’s ISP and interviewed staff and witnesses.

Based on all information obtained, the allegation is UNSUBSTANTIATED. An unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of this report provided.