Complaint Investigation Report

100400070-3-4-2026-24-AS-AWAN-DSQRCD-20260401125407

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

01/05/2026 and conducted by Evaluator Jimmy Duarte

COMPLAINT CONTROL NUMBER: 24-AS-20260105161419

Residents develop multiple pressure injuries due to staff neglect.

Residents develop multiple UTI's due to staff neglect.

Staff handle residents in a rough manner.

Staff do not ensure residents' hygiene needs are being met.

Staff do not provide adequate supervision to residents resulting in falls.

Staff do not ensure to provide residents' with fluids.

On 03/04/2026, Licensing Program Analyst (LPA) J. Duarte, arrived unannounced to conduct interviews and deliver findings. LPA introduced self, stated the purpose of the visit and met with Executive Director and Administrator Paul Rocha.

The Department conducted interviews and reviewed records. Based on the interviews conducted and records reviewed, the allegations; residents develop multiple pressure injuries due to staff neglect, residents develop multiple UTI's due to staff neglect, staff handle residents in a rough manner, staff do not ensure residents' hygiene needs are being met, staff do not provide adequate supervision to residents resulting in falls, and staff do not ensure to provide residents' with fluids are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur or did not occur; therefore, the allegations are Unsubstantiated.

An exit interview was conducted. A copy of this report was discussed and provided to Administrator Paul Rocha, whose signature on this form confirms receipt of this document.