Complaint Investigation Report

392700894-12-18-2024-27-AS-LKIG-DCSNTG-20250110094442

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

07/09/2024 and conducted by Evaluator Kesha Lewis

COMPLAINT CONTROL NUMBER: 27-AS-20240709103628

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deiver findings for the above allegations. LPA was greeted by administrator and explained the reason for the visit.

An Indepedent investagation was done by the department and based on the records reviewed, There is not enough evidence to suggest that there was a facility failure that caused R1’s SBI and death. There is no preponderance of evidence to prove the alleged violation contributed to the resident’s death or injury due to R1’s complex co-morbidities and other contributing factors. The facility was able to provide proof of reoprting the incident within the allowed time frame. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. No deficiencies were cited regarding the above allegations

Exit interview conducted. Copy of report given