Complaint Investigation Report

079200575-12-29-2022-15-AS-KHOS-CMRNSZ-20230104094357

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

12/19/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20221219112734

An insufficient number of competent facility personnel are present at all times within the facility to provide the services necessary to meet resident needs.

On 12/29/22 at 1:40PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with interim Health Director, gathered information and delivered investigation finding. LPA explained the purpose of the visit with IHD.

Based on record reviews and interviews which were conducted, IHD confirmed with LPA that a med tech was assigned 2 med carts to pass medications to residents as evidenced by signed medication administration records in December 2022 due to short staffing. The preponderance of evidence has been met. Therefore, this allegation is 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.