Complaint Investigation Report

075601547-11-24-2021-15-AS-KHOS-C9CHJL-20211203051431

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

11/17/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20211117110613

Staff are falsifying COVID vaccination records

On 11/24/21 at 2:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, gathered information relevant to the allegation and delivered the investigation finding to staff (S1) and administrator (ADM). LPA explained the purpose of the visit with S1 and ADM.

S1 gave a random sampling of COVID-19 vaccination cards (8) to LPA during visit. Based on record reviews and observation, each card contained the product name/Manufacturer lot number, date of 1st dose/2nd dose and clinic site.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited. Exit Interview conducted and a copy of this report provided to Administrator.