Complaint Investigation Report

079200924-12-23-2021-15-AS-KHOS-CRFNQ3-20230502103914

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

12/17/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20211217090145

On 12/23/2021 Licensing Program Analyst (LPA) L. Ibo visited the facility to conduct initial 10 days visit . LPA explained that the reason for the visit that above complaint allegations of was filed . LPA met with Administrator Mary Malekamu.

During the complaint investigation LPA conducted document review & observation. LPA requested for physician’s report from Administrator. LPA observed that staff are not wearing mask during the visit.

Based on LPA interview and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of Appeal Rights and this report provided.