Complaint Investigation Report

157209316-10-28-2025-24-AS-AWAN-DT8VD8-20260417162018

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

10/13/2025 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20251013113355

Staff did not ensure consumables provided to resident were free from contamination.

On 10/21/25, Licensing Program Analysts (LPAs) L. Salazar and S. Doucette arrived to the facility unannounced to conduct the required 10-day site inspection. LPAs were greeted by staff, stated the purpose of the visit and were allowed entry. Administrator arrived to the facility shortly after.

Based on LPAs observations and interviews conducted, Resident R1's lemondade had 4 small mold spores. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter 8, is being cited on the attached LIC 9099D. If not corrected, the violation will have a potential risk to the health, safety, or personal rights of clients in care.

An exit interview was conducted with Administrator. A plan of correction was developed by Administrator and reviewed with LPA. A copy of this report and appeal rights were discussed and provided at the time of visit.