Complaint Investigation Report

415600874-1-25-2023-14-AS-KHOS-CPNPRV-20230306103322

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SF COASTAL AC/SC , 851 TRAEGER AVE., SUITE 360

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

12/23/2022 and conducted by Evaluator Jaime Vado

COMPLAINT CONTROL NUMBER: 14-AS-20221223155140

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the above allegations. LPA met with the executive director Monica Tapia and explianed purpose of today's visit.

During the course of the investigation LPA condducted interviews and reviewed the eviction notice provided to the resident. Upon review of the eviction notice, as well as the resident's physician's report, and the facility assessments/reappraisals show that the only basis of eviction states the fact that the resident having dementia is the primary reason. The physicians report (LIC602) and assessment do not state other reasons for eviction. This allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reveiwed with executive director Monica Tapia.