Complaint Investigation Report

342700186-10-17-2024-59-AS-MSEY-DGUNP9-20250520103754

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

06/21/2024 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20240621115513

Facility staff do not store cleaning chemicals locked and inaccessible to residents in care

Licensing Program Analsyt (LPA) Cassie Yang arrived unannounced at the facility to investigate the allgation above. LPA met with Administrator and explained the purpose of the visit.

Based on observation during a tour, LPA found two Shout chemicals left in resident's room with door left opened. LPA took two photos of the following and stopped a caregiver on the floor to retrieve the chemicals. During the time of observation, there was two other residents walking with LPA. Interview conducted with Administrator revealed it may have been from resident's family member as facility does not use the following.

The allegation is 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 allegation cited above is substantiated, please see LIC9099-D.

Exit interview and a copy of the report and appeal rights was provided.