Complaint Investigation Report

Based on interview, Administrator admitted that when R1 was hospitalized, S2 attempted to call R1’s responsible party to report about the incident but unfortunately the phone numbers listed on R1’s chart was incorrect and responsible party was not aware of the incident not until hospital staff called R1’s responsible party.

Based on records review, S1 provided a copy of unusual incident report to LPAs that was found on R1’s chart, but Administrator failed to provide proof that this unusual incident report with incident dated 11/22/2022 was sent to CCL.

Based on information obtained, the preponderance of evidence is met, therefore the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan of correction were discussed with Administrator.

Exit interview conducted, Appeal Rights, LIC9099D, and a copy this report provided.