Complaint Investigation Report

079200784-4-5-2024-15-AS-KHOS-D4CGYY-20240415054616

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

03/28/2024 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20240328084742

Administrator accepted resident without proper paperwork or signatures from the authorized representative

On this day at around 10:00 am, Licensing Program Analysts (LPAs) K. Nguyen and L. Holmes arrived unannounced to conduct investigation on the above allegations. LPAs met with caregiver Annie Perez and explained the purpose of visit. LPAs informed Administrator Meeran Saxena the purpose of visit. Administrator arrived at the facility at a later time.

During the course of investigation, LPAs interviewed Administrator Meeran regrading the above allegation. Administrator confirmed to LPAs that she does not have R1 Physician's Report, Admission Agreement.

Based on interview conducted, Resident 1 (R1) has a diagnosis of Dementia and trying to get in contact with R1 POA to get all the documentation sign. Documents that was being provided is from the previous facility and not for this facility.

Based on LPA interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22. Deficiencies are being cited on the attached LIC 9099D.

Exit interview was conducted with Meeran. Appeal Rights was provided via email.