Complaint Investigation Report

079201007-12-17-2021-15-AS-KHOS-CA4LJ5-20211227074724

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

12/14/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20211214114129

On 12/17/21 at 11:53AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with administrator and explained the purpose of the visit.

LPA observed 3 masked staff assisting 2 clients with snacks in the kitchen while the other clients were resting inside their bedrooms.

During investigation, LPA interviewed administrator, S1 and S2. Based on LPA’s observations and interviews which were conducted and record review(s), facility did not have the required staff to provide 1:1 care and supervision for a respite client on the night shift (NOC). The preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.