Complaint Investigation Report

107209183-4-6-2022-24-AS-SPIY-CDHV2U-20220415160344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

03/14/2022 and conducted by Evaluator Les Xiong

COMPLAINT CONTROL NUMBER: 24-AS-20220314132847

Facility did not issue refund to resident's authorized representative.

Licensing Program Analyst (LPA) L. Xiong conducted the subsequent complaint investigation visit to the facility. I met with La Shay Ayers, Administrator and informed her the purpose of visit. During the course of this complaint investigation LPA interviewed staff and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. Facility did not issue refund to resident's authorized representative. It was discovered that there were no Admission Agreement signed between the authorized representative and the facility. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)