Complaint Investigation Report

397000250-8-24-2021-27-AS-KHOS-C7GJ8T-20211004065002

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

08/24/2021 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20210824095221

Facility staff are not present at the facility

On 8/24/21 at 1:53pm Licensing Program Analyst (LPA) arrived unannounced to open and investigate the complaint allegation listed above. LPA met with Administrator Maricor Camero and explained the purpose of the visit. During the course of this investigation LPA reviewed resident1 (R1)'s Individualzed Program Plan (IPP) as well as staffing roster and resident roster. LPA also conducted interviews with Administrator, Staff1 (S1) and R1. Based on interviews it was determined that on 8/20/21, R1 was left in the facility alone with no supervision for approximately 1 hour while Administrator and S1 were out of the facility with other residents. Based on interviews it was determined that there was no additional staff available for supervision of R1 during this time.

Based on interviews and record reviews it is determined that this allegation meets the preponderance of evidence standard and is therefore SUBSTANTIATED. Defeciencies were cited under TItle 22, Divsion 6 on form 9099D. A copy of this report and appeal rights were left with Administrator Maricor Camero.