Complaint Investigation Report

312700958-4-1-2026-59-AS-TORZ-DTDQH2-20260422121022

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

03/24/2026 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20260324135409

Staff did not refund authorized representative after resident passed away

On (date), Licensing Program Analyst (LPA) Kevin Mknelly spoke to Administrator,s designee, to deliver complaint findings for the above allegation. LPA also spoke with Admistrator by phone.

LPA reviewed resident records, and conducted and interview of the Administrator.

LPA finds that the allegations cited above are substantiated.

Records and interviews found that R1 passed away 4 days after admission and was receiving hospice care. R1 was admitted on 1/25/26 and passed away on 1/28/26. Belongings were removed from the home on 1/28/26 so R1 was a resident for 4 days.

Administrator acknowledged that refund fees have not yet been paid

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 . Copy of this report and appeal rights provided.