Complaint Investigation Report

157203255-9-19-2025-24-AS-SPIY-DLUKHW-20250925075548

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

06/30/2025 and conducted by Evaluator Melinda Medina

COMPLAINT CONTROL NUMBER: 24-AS-20250630120845

Facility staff did not seek timely medical attention for residents resulting in hospitalization

On 09/19/25, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to deliver findings. LPA introduced self, stated purpose of visit, and allowed entrance by House Manager, Pamela Carter.

This department investigated the above allegation, during the investigation, facility was toured, interviews

conducted and records reviewed. Based on information gathered during interviews and incident reports received by department, there was a delay in R1 receiving follow up medical treatment as ordered by physician on 6/18/25. On 6/19/25, R1 had a fall resulting in a head injury, 911 was not called. R1 was transported to ER several hours later by staff for treatment and was hospitalized.

Based on interviews and records review, and per California Code of Regulations, Title 22, Division 6, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited on the attached 9099-D. If not corrected, this poses an immediate risk to the Health Safety and/or personal rights of residents in care. An immediate civil penalty in the amount of $500 is being assessed for care and supervision. Issuance of additional civil penalties, if any, are pending and currently under review.

Exit interview conducted with House Manger, Pamela Carter. A copy of this report and appeal rights were discussed and provided for facility records. A plan of correction developed and reviewed with LPA.