Complaint Investigation Report

Record review reveals that R1’s daughter had been the primary contact and completed/signed all admission documents. The facility Admission Agreement lists R1’s daughter as the Responsible Party. R1’s daughter was not notified of the incident by the facility. R1’s daughter was not aware that R1 was hospitalized until contacted by the hospital.

Based on interviews and record reviews, The preponderance of evidence standard has been met, therefore both of the above allegations are found to be SUBSTANTIATED .

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

Civil penalties are pending and currently under review. The details of the civil penalties will be outlined in a future report to the facility.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Mario Ramos, whose signature on this form confirms receipt of these documents.