Complaint Investigation Report

342701325-7-18-2025-27-AS-KHOS-DK3PGG-20250730111819

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

03/21/2025 and conducted by Evaluator Sommer Hayes

COMPLAINT CONTROL NUMBER: 27-AS-20250321131446

Staff did not administer medication to a resident in care.

Licensing Program Analysts (LPAs) Sommer Hayes and Kimberly Viarella arrived to continue the investigation of the above-mentioned allegation on April 9, 2025. LPAs introduced themselves and stated the purpose of the visit. The Designated Facility Administrator was not available, and LPAs met the Designee, Chinenye Obiago. They arrived shortly after LPAs arrival.

This investigation consisted of interviews and record review. Interviews were conducted with resident (R1), one staff member (S1) and the designee, Chinenye Obiago. LPAs reviewed an incident report to Alta Regional Center dated 03/13/25, a copy of an email from R1 to their RP dated 03/12/25, medication records for R1 dated 01/01/24-04/09/25, ongoing notes/care notes for R1 dated 03/01/25-03/17/25.

An interview with Chinenye Obiago stated that 03/07/25, in evening, the staff noticed that R1 was out of their medication. Since it was the evening the responsible party (RP) of R1 was notified the next day on 03/08/25. Medication was ordered on 03/08/25, by R1’s RP. The medical administration record revealed R1 did not receive medication for 11 doses. On 03/13/25 at 6:00pm R1 was exhibiting a change in condition and demonstrating aggressive behaviors. Administrator,Toghararanrosae Omatseye called Elk Grove Police Department and R1 was taken to the hospital for evaluation. R1 was discharged on 03/15/25.

The preponderance of evidence standard has been met; therefore, the above allegation(s) are found to be SUBSTANTIATED.

During this investigation, LPAs learned the following:

The facility did not report the incident to Community Care Licensing as required.

The facility did not obtain an LIC 602 for R1 prior to admission which was also required.

Both of these deficiencies will be addressed in a case management at a later date.

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 report and their appeal 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.