Complaint Investigation Report

157209329-1-9-2025-24-AS-SMOA-DCVM83-20250113082228

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

12/02/2024 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20241202160513

Staff did not seek medical attention for resident in care in a timely manner

On 01/08/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to delivered complaint findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to met with Administrator. Licensee Jason Johnson was called and stated unable to attend meeting. Licensee authorized House Supervisor Diana Diaz to recieved and sign report. House Supervior arrived shortly. LPA met with House Supervisor.

During the course of the investigation, records were received, interviews were conducted, and facility was toured. R1 was found unresponsive inside the facility, staff did not seek medical attention. Based on interviews conducted and records received, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to the House Supervisor, whose signature on this form confirms receipt of this report.