Complaint Investigation Report

216804022-4-28-2023-21-AS-CMAZ-CRGUM8-20230503154152

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

02/03/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20230203120245

Resident(s) have sustained multiple falls due to lack of supervision.

Facility staff did not dispense medication to resident as prescribed.

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegations. During the course of this investigation, this Department has made site visits, intrerviewed staff and witnesses, obtained and reviewed documents. The following determinations are made: Complainant has not provided sufficient information regarding dates and medication names to fully investigate the medication allegation; the Department has shown that a medication for R1 was not administered as ordered on 12/1 and 12/2; There was a delay in obtaining the medication, however, which involved the Responsible Person's response in providing the medication; a review of resident falls during the approximate period of two months prior to the receipt of this complaint, does not substantiate the allegation that the falls resulted from a lack of staff supervision; High fall risk residents identified were on fall management programs; Care notes reviewed suggest appropriate staff responses to resident falls; Origins of some identified falls are unknown but sufficient evidence to link falls to non supervision was not found. Although the allegations may be true, based upon the statements, records, and lack of supporting details, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, it is UNSUBSTANTIATED.