Complaint Investigation Report

157209417-9-25-2025-24-AS-AWAN-DM4UFE-20251003153236

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

09/12/2025 and conducted by Evaluator Jimmy Duarte

COMPLAINT CONTROL NUMBER: 24-AS-20250912104637

On 09/25/2025, Licensing Program Analysts (LPAs) J. Duarte and L. Salazar arrived at the facility unannounced to continue the investigation and deliver findings on the above allegations. LPAs were greeted by current Administrator (AD) Jessica Pelaya. LPAs stated the purpose of the visit.

LPAs toured facility with AD, reviewed facility records, interviewed residents and staff, reviewed residents files, and observed two individuals not on the facility schedule as employees, had personal belongings in rooms 166 and 269 and staff reported that they reside there. A Civil Penalty in the ammount of $500 for Criminal Record Clearance is here by assessed.

LPA J. Duarte observed room 174 to be floaded and with an industrial fan operating to air out the room. LPAs also observed multiple resident rooms and hallways throughout the facility with dirty and/or stained carpet, toilets, and showers. In addition the kitchen tiles have dirt built up in the groute.

LPAs reviewed resident records and interviewed R1, who stated went to the hospital on two occassions. A review of facility files, shows no incident report was submitted for R1's hospital visit.

Based on the information received, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. A Civil Penalty in the ammount of $500 per individual totaling, $1,000 for Criminal Record Clearance is here by assessed on LIC421BG.

An exit interview was conducted with AD and a plan of correction was developed by 10/02/2025. A copy of this report and appeal rights were discussed and provided at the time of visit.