Complaint Investigation Report

331880552-2-15-2022-18-AS-EMAN-CHLUFR-20220824153310

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1650 SPRUCE ST STE 200 MS29-27

This is an official report of an unannounced visit/investigation of a complaint received in our office on

05/15/2020 and conducted by Evaluator Jennifer Semin

COMPLAINT CONTROL NUMBER: 18-AS-20200515090558

Facility is retaining resident requiring a higher level of care

Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to the facility to deliver the findings for the above complaint allegation. LPA met with Caregiver, Eddie Dabu. Administrator Anna Bella Vito was notified via telephone.

The investigation consisted of interviews and record review. The allegation, Facility is retaining resident requiring a higher level of care. Facility staff stated staff did give R1 their medication and did check their blood sugar. Staff stated staff did not take R1 to any doctor or lab appointments. Staff stated R1 was transported to the hospital per physician’s request and admitted to a higher level of care. R1 could not corroborate or refute the allegation.

Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to Ms.Vito via telephone and Mr. Dabu