Complaint Investigation Report

397005738-10-11-2024-27-AS-KHOS-DAQQ9Z-20241105105910

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

08/23/2024 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20240823100640

On 10-11-24 at 12:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator William Puckett and explained the purpose of the visit. During this investigation, LPA conducted interviews with two staff and an additional eyewitness. LPA also reviewed additional documentation including a restraining order dated 4-5-24, and a written declaration received from witness. Based on interviews and record reviews, it was revealed that resident1 (R1) was receiving supervision from staff3 (S3) on 4-5-24 and pushed by S3 during an attempt to redirect behavior. Interviews and record reviews revealed specifically, that R1 was attempting to walk forward when S3 placed hands on R1’s shoulders and pushed S3 with force strong enough to cause S3 to stumble backwards. No known injuries to R1 resulted from this event. Incident was reported to local law enforcement who issued a temporary restraining order to S3 due to the occurrence as noted above.

As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided.