Complaint Investigation Report

336410691-4-10-2023-18-AS-KCLS-CRBSMQ-20230428140019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

07/09/2020 and conducted by Evaluator Rayshaun Nickolas

COMPLAINT CONTROL NUMBER: 18-AS-20200709152202

Resident sustained multiple pressure injuries while in care.

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations LPA met with Executive Director III Denise Flores and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties.

The allegation alleged that resident #1 (R1) was admitted to the hospital on July 8, 2020. The allegation alleged the client had pressure injuries on their back and right calf. LPA Nickolas’ facility file review revealed that R1 was non-ambulatory, according to R1’s physician’s report. However, facility staff could not find all R1’s medical records because R1 moved out of the facility on July 30, 2020, and their files were archived. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and copy of this report was provided.