Complaint Investigation Report

197609872-9-23-2022-31-AS-CHAS-CKN2BN-20221028171524

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 21731 VENTURA BLVD., STE. 250

This is an official report of an unannounced visit/investigation of a complaint received in our office on

09/19/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220919172357

LPA Spaeth conducted an unannounced visit and was greeted by staff member at the front door. LPA stated the purpose of the visit was to conduct an investigation regarding the allegation, Facility staff are not wearing masks. LPA obsered two caregivers who were assisting residents with breakfast and both were wearing a mask.

The Administrator arrived at 8:20 am and LPA observed Administrator was not wearing a mask. LPA advised Administrator to wear a mask and discussed the facility's infection control plan states all staff must wear a mask when entering the facility. The allegation therefore is substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.