Complaint Investigation Report

331881086-12-28-2022-18-AS-DMUN-CN6TS5-20230117135835

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

09/09/2021 and conducted by Evaluator Jesse Gardner

COMPLAINT CONTROL NUMBER: 18-AS-20210909080603

Michael Maeda, Resident Services Director

Staff did not inform resident's authorized representative of issues concerning resident

Licensing Program Analyst (LPA) Jesse Gardner arrived a the facility and met with Resident Services Director (RSD) Michael Maeda. LPA Gardner made Maeda aware of the above allegation and toured the facility.

It was alleged that R1 had several falls while residing at the facility and R1's Power of Attorney (POA) was not notified of the falls. Through documentation provided by the facility, LPA found that on 11/12/2020, and on 11/28/2020, R1's POA was notified of falls; however, per R1's Admission Record, there were (2) POA's listed as responsible parties. Both POA's should've been notified of R1's falls. Therefore, this complaint was SUBSTANTIATED, and the facility was cited per Title 22.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC9099-D, and Appeal Rights.

This is an amended version of the original dated 10/19/2021.