Complaint Investigation Report

392700516-8-24-2021-27-AS-KHOS-C6NM4Q-20210908091706

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 2525 NATOMAS PARK DR. STE.270

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

08/20/2021 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20210820145241

Staff did not file special incident report in a timely manner

On 8/24/21 at 3:57pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to open and investigate the complaint allegation listed above. LPA met with Royal Young, licensee and explained the purpose of the visit. During today's visit, LPA interviewed licensee who stated an incident report was faxed to regional center on 8-8-21 for an incident occurring on 8-1-21. LPA also interviewed Administrator during today's visit. LPA reviewed fax confirmation log which indicated a fax was sent to regional center on 8-8-21, but no confirmation to indicate a faxed incident report was sent to licensing agency within 7 days of occurrance. Additionally, there is no confirmation that report, verbal or written was made to licensing agency by department's next working day. LPA reviewed incident report for resident1 (R1) dated 8-1-21 and confirmed the incident report which indicated a threat to emotional health and safety of a client has not been received by licensing agency to date. Licensee faxed incident report to licensing department during today's LPA's visit. Based on record review and interview it is determined that an incident occurred on 8-1-21 and not reported to licensing department in a timely manner, therefore, this allegation is SUBSTANTIATED. An exit interview and a copy of this report and appeal rights was left with Licensee Royal Young.