Complaint Investigation Report

157209146-12-11-2024-24-AS-SPIY-DC5UYJ-20241220150001

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

10/16/2024 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20241016102317

Staff do not prevent resident from leaving the facility unassisted

Licensing Program Analyst (LPA) Shawna Doucette (LPA) conducted a visit to deliver findings. LPA discussed the purpose of the visit and the elements of the allegations with Caregiver/Office Staff Jan Krizia Adajar. Administrator Nancy Cudal gave permission for Caregiver/Office Staff Jan Krizia Adajar to sign for this report.

LPA reviewed records and interviewed staff. LPA obtained copies of residents file, which was incomplete. Facility did not have a completed LIC 602 signed by a doctor. Facility has LIC 601 completed but not signed. Admissions agreement was signed, but was incomplete Pre Placement Appraisal was blank and Needs and Service Plan was blank. Centrally stored log was complete. Due to lack of documentation, LPA was unable to determine if R1 can leave facility unassisted.

Based on record reviews and interviews, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.