Complaint Investigation Report

157208910-6-1-2022-24-AS-MHON-CF6SEB-20220607134827

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

01/18/2022 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20220118082443

On 05/31/22, Licesning Program Analyst (LPA) L. Salazar arrived at the faciity unannounced to deliver findings on the above allegations. LPA was greeted by Staff S1, stated the purpose of the visit, and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry.

During the investigation, LPA reviewed facility records that included a corrective pllan of action for Staff S3. LPA reviewed resident records that include Individual Performance Plans (IPP) for Resident R1 and Resident R2. LPA interviewed R1 and R2 and staff.

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.

An exit interview was conducted with Administrator vis telephone and Staff S2. A copy of this report and appeal rights were discussed and provided to the facility. A plan of correction was developed by Administrator and reviewed with LPA.