Complaint Investigation Report

275294324-8-31-2022-24-AS-MHON-CN6UXK-20230117145829

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

08/08/2022 and conducted by Evaluator Melinda Medina

COMPLAINT CONTROL NUMBER: 24-AS-20220808120217

On 8/31/2022, Licensing Program Analyst (LPA) M. Medina conducted a subsequent complaint visit. LPA introduced self, stated purpose of visit, and allowed entrance into facility. LPA met with Licensee, Herman Fickerwirth and Administrator, Michael Hagerty.

LPA Medina toured entire facility with Licensee and Administrator. LPA observed that there are currently 9 residents residing in facility of which 3 are identified as independent living. LPA observed 2 bedrooms (R1 & R2) to have exit doors being blocked.

Based on LPA observation and interviews, the preponderance of evidence standard has been met therefore the allegation is found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An immediate civil penalty of $500 is assessed.

An exit interview was conducted with Michael Hagerty, Administrator. A copy of this report and appeal rights were discussed and provided.