Complaint Investigation Report

312700901-8-15-2023-59-AS-KHOS-CW3FX3-20230927045203

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO NORTH ASC , 9835 GOETHE ROAD, SUITE 100

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

07/27/2023 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20230727143011

On 8/15/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Anita Haydon, Administrator, to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted extensive interviews.

LPA finds that the allegations cited above are substantiated.

LPA found that by having 6 residents and the Administrators family member residing at the home and receiving care from caregivers also, the facility was over their fire clearance capacity of 6 residents. On 8/4/23, R1 was in process of moving from the facility. Licensee will continue to include family member, R4, as a resident as long as R4 resides at the facility and receives care from caregivers.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Anita Heydon . Copy of this report and appeal rights provided.