Complaint Investigation Report

392700391-1-27-2022-27-AS-KHOS-CBBMYE-20220204090126

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

01/26/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20220126113038

On 1-27-22 at 1:56pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate complaint allegation noted above. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA interviewed Administrator and reviewed facility admission agreement for resident1 (R1), physician report for R1, and requested copy of pre-admission appraisal for R1. LPA also interviewed hospital case manager. Based on interview and record review it was determined that R1 was discharged to the hospital on 1-24-22 and was not intended to be accepted back when ready for return. Upon further interview, it was determined that a 30-day notice was not issued in accordance with Title 22 regulations and per admission agreement.

Based on interview and record review, it is determined that the preponderance of evidence standard is met. Therefore, this allegation is SUBSTANTIATED. Deficiencies are cited under Title 22 regulations, Division 6, Chapter 8. An exit interview was conducted with Adetayo Kokumo and a copy of this report was left with Kokumo. Appeal rights provided.