Complaint Investigation Report

079200074-4-5-2023-15-AS-KHOS-CQYQ3T-20230417114915

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

09/16/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210916132752

Resident sustained unexplained injuries while in care

On 04/05/2023 at 12:40PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver findings for the above allegation. LPA met with Ryan Bussalachi and explained purpose of the visit.

Allegation: Resident sustained unexplained injuries while in care

Based on LPA’s observation on 09/23/2021, C1 had bruises on the back left of his shoulder blades, redness and skin peeling was also observed.

Civil penalty of $500.00 was issued on today’s date.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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.