Complaint Investigation Report

107208889-7-11-2025-24-AS-SMOA-DJZMJ4-20250728093829

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

04/10/2025 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20250410163831

Facility does not have proper fire clearance

On 07/11/25, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced subsequent

complaint investigation and met with Assistant Administrator Lisa Pua.

During the course of the investigation, the Department conducted interviews, reviewed records, and toured the facility. The facility has no fire clearance for bedridden resident and has admitted R1 a bedridden resident to the facility.

Based on observation, interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 is being cited on the attached Lic 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator Assistant, whose signature confirms receipt of this report.