Complaint Investigation Report

312700019-4-24-2026-59-AS-TORZ-DTRNT2-20260504104400

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

02/23/2026 and conducted by Evaluator Graham Gunby

COMPLAINT CONTROL NUMBER: 59-AS-20260223155312

Facility staff did not adequately address a change in residents health condition to prevent falls

On April 24, 2026, Licensing Program Analyst (LPA) Graham Gunby conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA Gunby met with Executive DIrector, Kristine Clawson, and explained the purpose of the visit.

During the investigation process, interviews and a review of records were initiated. Documents reviewed showed that R1 is a fall risk and have had several falls in the past. R1 requested the facility remove the carpet in their room to have the same flat surface throughout their apartment.

Based on interviews it was indicated that R1's change in condition was addressed immediately. Interviews conducted with the Executive Director and R1, a solution was developed for this situation which resulted in R1 receiving different flooring to prevent falls in the future. An interview with R1 concluded there were no concerns and their problems have been resolved with the facility.

Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was emailed to ED.