Complaint Investigation Report

045002775-3-23-2026-59-AS-LCRR-DSKUP8-20260327154506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO NORTH ASC , 9835 GOETHE ROAD, SUITE 100

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

07/23/2025 and conducted by Evaluator Kayla Adkison

COMPLAINT CONTROL NUMBER: 59-AS-20250723170249

Resident sustained wound injuries due to staff's neglect

On March 23, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA Adkison was greeted by Amanda Harb, Resident Care Cooridnator (RCC), and explained the purpose of the visit. During the visit, there were 28 residents and 4 staff providing care.

Department of Social Services-Community Care Licensing Division-Investigations Branch, Investigator Blatnick obtained and reviewed records, interviewed staff members and witnesses. In addition, Investigator Blatnick reviewed medical records and facility records.

Allegation: Resident sustained wound injuries due to staff's neglect

It was alleged that R1 sustained bilateral foot wounds caused by a fungal infection due to staff's neglect.

Investigator Blatnick reviewed faciity records and hospital records as well and conducted interviews with facility and Home Health staff. R1 was unable to provide a statement related to the allegation. Based on statements obtained and the records reviewed, Investigator determined it was unclear if staff neglect resulted in the wounds.

Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Exit interveiw conducted and a copy of this report was provided to Administrator, Grace Hawkins, via email.