Complaint Investigation Report

361881035-3-20-2023-56-AS-NBRN-CQKP2V-20230404105635

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1650 SPRUCE ST STE 200 MS29-27

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

11/04/2022 and conducted by Evaluator Anna Bueno

COMPLAINT CONTROL NUMBER: 56-AS-20221104151616

Licensing Program Analysts (LPA) Anna Bueno and Licensee Najeh Hamed met at the San Bernardino Regional Office on this day. The Department investigation consisted of resident and staff interviews, resident records review, and observations of the physical plant.

It is alleged that the Facility is operating over capacity. Nine of nine records were reviewed and 3 non-ambulatory residents were found. This facility is licensed for two non-ambulatory residents who may only occupy the first floor bedroom, and no Dementia care plan was submitted to and approved by the Department. This allegation is therefore substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This poses a potential risk health and safety risk to residents in care. Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Licensee