Complaint Investigation Report

342701191-6-14-2024-27-AS-KHOS-D6CQN9-20240618121847

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO SOUTH ASC , 9835 GOETHE ROAD, SUITE 100

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

06/13/2024 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20240613165603

Facility did not provide resident records upon request

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegation on 6/14/24 at 12:15pm. LPA met with Caregiver Arinanne Dagohoy who contacted the Administrator regarding the purpose of the visit. LPA interviewed Administrator #1 (Adm 1) and (Adm 2) and Staff 1 (S1) during this visit. The investigation revealed that a copy of the residents file was not provided to the attorney of resident #1 (R1).

Based on confirmation through interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.