Complaint Investigation Report

315002894-11-13-2025-59-AS-MSEY-DNJTWV-20251118140608

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

09/25/2025 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20250925163842

Licensee does not ensure resident files are properly managed

On 11/13/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Louis Dizon, designee to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted interviews.

LPA finds that the allegations cited above are substantiated.

Records review and interview found that on R1 had a fall that required assessment and lift assist by emergency responders. LPA records review found R1's file to be incomplete- lacking admission agreement, ID and emergency contact information and a pre-appraisal.

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. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

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