Complaint Investigation Report
392700879-7-18-2025-27-AS-LKIG-DKY3RT-20250827182916
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
04/14/2025 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20250414094952
The facility did not observe the clients Personal Rights.
The facility mismanaged the clients Medication.
The facility failed to meet Reporting Requirements.
On 07/17/25, Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to facility.LPA Lewis discussed the purpose of the visit and the elements of the allegation with Staff.
Regarding the allegations the facility did not observe the client’s personal rights, the facility mismanaged the client’s medication, and the facility failed to meet Reporting Requirements. During an interview the administrator Arvin Davis admitted medication was given to the resident (R1) after it was discontinued by the doctor. During the same interview the administrator admitted that an incident report was not sent to the department and was then sent to LPA Lewis after the visit to the facility.
therefore the above allegation is found to be SUBSTANTIATED.Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit.
An exit interview was conducted, and copies of the report and appeal rights left.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction