Complaint Investigation Report

312700314-9-9-2025-59-AS-MSEY-DLJQ6M-20250915115346

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

07/10/2025 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20250710154744

Staff retained a resident with a prohibited health condition

Due to staff neglect, resident sustained a pressure injury

Due to staff neglect, resident sustained multiple bruises

Staff did not notify authorized representative of incident

On 9/9/25, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Administrator to deliver investigation findings.

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

LPA finds that facility met Tittle 22 requirements.

Records and interviews found that licensee identified and sought medical care for a pressure injury that started internally then surfaced. Records show R1 received a Dr. office visit, ultrasound to assess, and 2 ER visits before the wound was staged. R1 was hospitalized before returning to the home on hospice. Once the wound was staged, R1 was not retained in the home.

R1 has advanced denmetia and mobility issues. Bruises were noted as incidental to R1's, at times, uncontrolled movement while in bed.

Throughout R1's care, R1's spouse is a resident. Husband and family share POA and are regularly informed of R1's status.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and report provided.