Complaint Investigation Report

315002853-5-1-2025-59-AS-MSEY-DGESTG-20250506140932

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

02/25/2025 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20250225091336

Staff do not ensure resident is provided incontinence care in a timely manner

On 5/1/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to caregiver and house manager (by phone) to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted extensive interviews. LPA interviewed R1 during this visit.

LPA finds that the allegations cited above are substantiated. Statements by R1 and caregivers found that there had been a prior incident where R1 had incontinence and the caregiver present was not able to do incontinence care alone. The other staff for the shift had checked with R1 before leaving for a break and R1 did not have a care need. While that staff was on break, R1 experienced incontinence. The incontinence care was provided when there were two staff present. This caused a delay in R1's care. The facility has since made changes to staff scheduling and there have been no further incidents.

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 caregiver . Copy of this report and appeal rights provided.