Complaint Investigation Report

157202532-4-22-2026-24-AS-SDOE-DU2LJ2-20260513084713

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

04/12/2026 and conducted by Evaluator Katie Brown

COMPLAINT CONTROL NUMBER: 24-AS-20260412110332

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint visit. LPA met with and discussed the reason for the visit and the allegation with Interim Administrator (AD) Antwanique Walker.

During this visit, LPA toured the facility and conducted interviews. Interview and review of Incident Report submitted by facility on 4/6/26 are consistent in reporting that on 4/5/26, Resident (R1) was walking out of their room, Staff (S1) pushed R1, resulting in R1 falling onto the floor. S1 was placed on unpaid leave as of 4/5/26. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

On 4/16/2026 a Case Management Visit was conducted by this department and a citation was issued for Personal Rights Violation. A citation will not be issued today. An exit interview was conducted and a copy of this report was provided.