Complaint Investigation Report

216803577-6-17-2025-21-AS-KMOA-DHYQ8B-20250625115628

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SANTA ROSA RO , 1450 NEOTOMAS AVENUE, STE. 100

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

03/17/2025 and conducted by Evaluator Anthony Loera

COMPLAINT CONTROL NUMBER: 21-AS-20250317144851

On 06/17/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Lead Staff, Tanya Barreto. During the investigation, LPA reviewed records, conducted interviews, and made observations.

Complaint alleges, Staff handled resident in a rough manner and staff speaks inappropriately to resident.

Based on LPAs observations, record reviews, and interviews of 4 of 5 staff and outside parties, the following determination have been made. Facility documentation was provided to LPA on 03/24/2025 showing staff (S1) was suspended due to speaking inappropriately to Client (C1), stating they would have to cancel C1s meeting with their mom as C1 was not following directions. Additional documentation received revealed C1 was seen by a physician to address back pain on 03/14/2025 after being "yanked" by S1. Therefore, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, is being cited on the attached LIC9099D. Appeal rights given.