Complaint Investigation Report

Allegation: Facility did not provide Ombudsman with roster of residents

During visit, Administrator confirmed with LPA that facility staff failed to provide residents’ roster to Ombudsman on 09/28/21 upon request because there was none to give (LIC 9020). Administrator stated they did not have a completed resident roster (LIC 9020) during that time. The preponderance of evidence standard has been met. Therefore, this allegation is substantiated.

Allegation: Facility failed to report resident injury

During visit, administrator confirmed with LPA that they did not submit an incident report regarding R1’s injury at that time. LPA observed no incident report was received at CCLD regarding this event from the facility. The preponderance of evidence standard has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099Ds. Failure to submit proof of corrections (POC) by plan of correction due dates 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.