Complaint Investigation Report

345002805-4-23-2026-59-AS-LMUZ-DTRQ6V-20260504115411

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

02/11/2026 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20260211120241

Resident sustained injuries due to staff neglect/lack of supervision.

On 4/23/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Administrator, Emanuel Dirar to deliver complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival.

Allegation- Resident sustained injuries due to staff neglect/lack of supervision. Unsubstantiated

The department conducted records review, facility observations and interviews with residents and staff to investigate this allegation. Medical assessments and hospice notes reflected that resident, R1 was fall risk and exhibit agitated behaviors. Video footage showed that on 2/6/26 around 2:31AM, R1 opened the courtyard door and walked out and at 2:32 AM staff member followed R1 to redirect R1 back into the community. Shortly after the footage shows staff grabbing a wheelchair and escorting R1 back into the building. Also, facility reported this incident to all relevant parties and sought medical care for R1 as needed. Based on gathered information, it was evaluated that even R1 got injured from this incident, it was not due to lack of care and supervision from the staff, therefore, this allegation was Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted. A copy of this report was left at the facility.