Complaint Investigation Report

079200775-10-30-2023-15-AS-HHUL-CYVU3Q-20231226141354

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

10/23/2023 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20231023113701

Facility did not provide a copy of resident's admission agreement to resident's authorized representative

On 10/30/2023 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with caregiver, Carleen Sablan and informed her the reason for visit. Administrator, Cynthia Huang arrived 45 minutes later.

During the course of investigation, LPA interviewed 2 residents and 2 staff. LPA obtained and reviewed R1's admission agreement. Interview with staff revealed that a copy of the admission agreement was not given to resident/authorized representative because they did not request for a copy.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.