Complaint Investigation Report

312700555-7-22-2022-25-AS-KHOS-CGQQ54-20220727115117

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 520 COHASSET RD., STE. 170

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

12/29/2021 and conducted by Evaluator Jacob Williams

COMPLAINT CONTROL NUMBER: 25-AS-20211229104720

Denise Carrillo, filling in as Business Office Director

Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 07/22/2022 to conduct a complaint investigation for the above allegation. LPA met with Denise Carrillo, who is filling in as Business Office Director as the Executive Director and Business Office Director are both out, and explained the purpose of the visit. Prior to the visit , LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask.

During today’s visit, LPA spoke with staff (S1, S2, and S3), toured the facility and reviewed documents. LPA observed five (5) staff not wearing masks, and only (1) staff wearing their mask. As a result of this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. A copy of this report and appeal rights were printed and provided to Denise Carrillo.