Complaint Investigation Report

216804022-1-24-2023-21-AS-CMAZ-CNGQV2-20230127112935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1450 NEOTOMAS AVENUE, STE. 100

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

11/30/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20221130172055

Facility vaccinated a resident without obtaining permission from resident's responsible party.

****This is an amended version of the original report*****

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Ric Pielstick and discussed the findings. During the course of this investigation statement were taken, site visits made, and documents obtained and reviewed. The following determinations are made: R1 has a designated responsible person; On or about October 27,2022, facility provided flu shot clinic for residents conducted by outside vendor and on facility premises; R1 received a vaccine at the clinic on 10/27: Responsible person for R1 did not consent to the procedure and, in fact, declined the vaccine in preference to obtaining the vaccine for R1 at a later date due to a recent medical procedure undergone by R1. Based upon the records reviewed and statements taken, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.