Complaint Investigation Report

045002696-9-18-2023-59-AS-KHOS-CWPPWX-20231017114127

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

08/16/2023 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20230816163819

Staff did not supervise resident while outside in extreme temperatures

On September 18, 2023, LPA's Boyles and Avila arrived to the facility unannouced for a complaint investigation visit.

On August 15, 2023, R1 was found unresponsive outside on the patio by another resident family member at approximately 4:11 PM. Per interviews with staff, R1 was taken outside after lunch by the receptionist who did not tell relay this information to other facility staff. R1 had been sitting outside for approximately 2 hours and 45 minutes, or longer when temperatures were increasing and reached 108 degrees (F) by 2:00 p.m. The temperatures were verified by a local city weather graph (timeanddate.com). When R1 arrived at the hospital their body temperature was 106.1 degrees (F).

Based on LPAs interviews which were conducted and record reviews, the preponderance of

evidence standard has been met; therefore, the above allegation are found to be SUBSTANTIATED. California Code of Regulations Title 22 and or the California Health and Safety Code are being cited on the attached LIC 9099D. Appeal rights left with Adminstrator.