Complaint Investigation Report

306005470-4-26-2022-22-AS-SSAS-CF6R7Q-20220607124644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 770 THE CITY DR., SUITE 7100

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

04/21/2022 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20220421083332

Inadequate staffing to meet resident's needs.

Licensing Program Analysts (LPAs) Edward Tapia and Michelle Reed arrived at the facility to discuss the complaint allegation. Upon arrival LPAs met with Staff He Le. Administrator (AD) Nick Mai was contacted and arrived at approximately 9:00 am. A tour of the physical plant was conducted. There were 3 residents present and the following was observed:

Staff He Le was present by himself and stated that he is the only staff working at the facility. Records were reviewed and interviews were conducted. Resident 1 and 2 present were non-ambulatory, had limited mobility and needed assistance with all ADL's due to their cognitive ability. Resident 3 did not have required paperwork present and LPAs noted that he needed assistance. Based upon observation, a review of records and interviews, the preponderance of evidence standard has been met and this allegation is substantiated.

See LIC9099D for cited deficiencies. An exit interview was conducted and a copy of this report and appeal rights were given to AD Nick Mai