Complaint Investigation Report

075601320-4-12-2023-15-AS-KHOS-CQYQ7B-20230417115451

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

04/11/2023 and conducted by Evaluator James Sampair

COMPLAINT CONTROL NUMBER: 15-AS-20230411154803

Resident's bed is blocked by another piece of furniture preventing passage around the room.

On 04/12/2023 at 8:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a complaint inspection. LPA explained purpose of the visit to Caregiver Evangeline Polito, who toured facility with LPA. Licensee Rosa Junsay arrived at 10:50 AM.

At 8:15 AM, LPA observed furniture matching that sent by Complainant in resident R1's room. When asked, Caregiver Polito confirmed that it was used to block R1's exit from the bed at night. Based on the data collected by observation and interview, the preponderance of evidence standard has been met; therefore, the above allegation has been found to be SUBSTANTIATED.

Deficiency cited per Title 22 California Code of Regulations is listed on the LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date 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.