Complaint Investigation Report

197608685-5-14-2023-31-AS-TAGD-CT9UZT-20230629160203

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

02/25/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200225154209

Staff failed to properly report incident to authorized representative

This is an amendment of the report issued on 04/27/23 to rectify a typographical error.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Business Office manager and informed the purpose of the visit.

LPA conducted physical plant tour at 9:30 AM, requested copy of facility documents relevant to the investigation and reviewed the same from 10:00 AM to 11:30 AM. LPA also conducted interview with staff from 11:30 AM to 12:30 PM. It was alleged that there was no communication from the facility about Resident #1 (R1) to family member (FM) being rushed to emergency surgery for a broken hip on 10/21/19. LPA's record review today between 10:00 AM to 11:30 AM revealed that staff called the family member of R1 and Primary Care Physician (PCP) on the night of the incident on 10/20/19 at around 11:30 PM. LPA's interview with the former Staff #1 (S1) today at 12:10 PM, who attended to R1 on the day of the incident, revealed that S1 was sure that S1 made the call to the family member of R1 after calling 911. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.