Complaint Investigation Report

126803830-12-23-2024-21-AS-BMOS-DCNQDT-20250106110515

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1450 NEOTOMAS AVENUE, STE. 100

This is an official report of an unannounced visit/investigation of a complaint received in our office on

12/17/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20241217090243

Staff made an inappropriate comment regarding a resident

At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Executive Director Roger Endert, reviewed records and interviewed staff. Based on interviews conducted, LPA was not able to find evidence to support the allegation that staff made an inappropriate comment regarding a resident. LPA reviewed records regarding resident care and observed a recent meeting discussing an agreed upon risk assessment based on resident care needs. LPA interviewed individuals that attended the meeting and was not able to find evidence that staff made inappropriate comments. LPA reviewed records and interviewed staff regarding resident pendant procedures. LPA was informed that a staff had removed a pendant from a resident. The staff member was preparing resident for bathing and removed the pendant and placed it on a counter. After assisting the resident, staff forgot to return the pendant to resident. Resident was without their pendant for approximately 4 hours, until staff was alerted to the situation. There were no issues in this timeframe. LPA reviewed the previous 90 days of pendant logs and observed resident had access to their pendant. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.