Complaint Investigation Report

157208773-9-23-2022-24-AS-SMOA-CJWTEN-20221005144011

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

07/14/2022 and conducted by Evaluator Vadim Gorban

COMPLAINT CONTROL NUMBER: 24-AS-20220714131348

On 09/21/2022 Licensing Program Analysts (LPAs) V Gorban and L Salazar arrived unanounced to the facility stated above. LPAs greeted and were allowed entry into facility. Covid protocol was observed.

During the investigation LPAs toured the facility and observed what appeared to be bodily fluids on the walls of all three hallways. LPAs observed multiple fly traps hanging from the ceiling, above the dining tables where residents were eating, light fixtures in the halls were observed to have cobwebs and bugs, Hallway doors leading to the outside courtyard were observed to be stained with dirt.

Based on LPAs observations, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is cited on the attached 9099D. If not corrected, this poses an potential risk to residents in care.

An exit interview was conducted with Administrator. A plan of correction was developed with Administrator and reviewed with LPA. A copy of this report and appeal rights were discussed and also provided to Administrator.