Complaint Investigation Report

107209183-10-3-2024-24-AS-KHOS-DCWP9J-20250114100713

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

09/30/2024 and conducted by Evaluator Martin Vega

COMPLAINT CONTROL NUMBER: 24-AS-20240930141721

Facility staff did not provide a supervision for resident, resulting in injury.

On 10/03/2024 LPA M Vega conducted an initial 10-day investigation to open the complaint. Staff 1 answered the door and contacted administrator La Shay Ayers. LPA met with Administrator a short time after and stated the purpose of the visit.

1. The Department investigated the allegation: Facility staff did not provide a supervision for resident, resulting in injury. LPA conducted facility tour and reviewed records for R1 and R2. Per review LIC 624 was sent by facility, reviewed form and fax confirmation page.

The Department has investigated the above allegations and have found them to be unsubstantiated. Exit interview conducted.