Complaint Investigation Report

107208889-12-2-2025-24-AS-SMOA-DQTPKV-20260130102344

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

07/24/2025 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20250724084651

Staff allow resident to stay in her soiled clothing for extended periods of time

Staff do not ensure resident is provided with transfer assistance to her chair

Resident developed minor pressure injuries while in care

Staff do not ensure residents call button is operational at all times

Staff did not ensure residents personal property was safely secured

Staff do not ensure resident is spoken to in an appropriate manner

Staff handled resident in a rough manner resulting in resident sustaining a bruise

On 12/02/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent investigation and deliver complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit and met with Assistant Administrator Lisa Pua.

During the course of the investigation, interviews were conducted, and facility was toured. The residents’ call buttons are functional and operational during visit. Based on interviews conducted, staff changes residents brief throughout the day and as needed. Staff attend R1 and assist R1 in transfer. Allegation alleging staff allow resident to stay in her soiled clothing for extending periods were investigation in complaint 24-AS-20250410163831 and found to be Unsubstantiated. Based on interviews conducted and records reviewed, there was insufficient evidence to prove or disprove that staff did not ensure R1 is provided with transfer assistance to the resident’s chair, resident developed minor pressure injuries while in care, staff did not ensure resident’s personal property was safely secure, staff spoke to resident in an appropriate manner and staff handled resident in a rough manner resulting in resident sustaining a bruise. Therefore, the above allegations are found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided to Assistant Administrator, whose signature on this form confirms receipt of this report.