Complaint Investigation Report

306006040-11-1-2022-22-AS-SSAS-CPZQHY-20230317121154

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

07/11/2022 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20220711174604

Lack of supervision resulting in resident suffering a fall and sustaining an injury.

Licensing Program Analyst (LPA) Michelle Reed met with Adminsitrator Jennifer Kornmann to discuss the complaint findings for the above allegation. The investigation consisted of interviews with Administrator, staff and witnesses as well as documentation from Resident #1's file. The following was determined:

Resident #1(R1) was admitted into the facility on April 22, 2022. R1 had Cognitive Impairment and according to records reviewed needed assistance with his activities of daily living. R1 was ambulatory and walked with a cane as he was unsteady. On July 8, 2022, at approximately 8:20pm Staff #1 found R1 on the floor of his apartment. R1 complained of head, knee and arm pain. 911 was immediately called. R1 was transported to the hospital. R1 sustained blunt trauma and returned to the facility using a wheelchair.

Based on the information gathered during the investigation, there was no supporting evidence of neglect or lack of supervision on the part of Clearwater staff that caused or contributed to R1’s fall. The allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Jennifer Kornmann and a copy of this report was provided.