Complaint Investigation Report

107203505-4-20-2022-24-AS-SPIY-CE4QFX-20220504120833

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

08/13/2021 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20210813150239

Resident's assistive device hit resident resulting in broken teeth.

Resident's responsible party was not informed of an incident involving resident getting injured.

On 4/20/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility for an unannounced complaint visit. LPA was met by Direct Care Staff, Annie Togonon. Administrator, Susan Kendakur was contacted and arrived a short time later. LPA toured the facility inside and out and completed a Health and Safety check on residents in care. Residents observed in common areas, in rooms and in office. LPA explained reason for visit with Adminsitrator.

During investigation interviews conducted and records reviewed. Special incident reports from the facility did not show that R1 was injured at any time during their residence at the facility. R1 was found to have a chip in the tooth during interviews. Staff interviews disclosed that the facility was unaware of any incident resulting in broken teeth. Althought the above allegations may or may not have occurred the preponderance of evidence does not meet the standard, therefore the above allegation is found to be UNSUBSTANTIATED per Title 22. No deficiencies cited. Exit interview conducted. Due to COVID precautionary measures reports will be emailed to: anjaleoni@icloud.com. A delivered and read receipts serving as confirmation.