Complaint Investigation Report

079200634-3-28-2022-15-AS-HHUL-CEXVQC-20220531163808

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

03/01/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210301114642

On 3/28/2022 at 1:00PM Licensing Program Analyst (LPA) L.Ibo arrived unannounced to deliver complaint findings for the allegation above. LPA met with Administrator, Staci Stevens.

During the course of investigation, LPA gathered the following documents but not limited to; SOC341, daily notes and termination document. Based on staff interview S1 was aggressive towards the resident in care, however, resident did not sustain any bruises or injuries. Facility suspended S1 on 3/9/2021 and was terminated on 3/10/2021.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.