Complaint Investigation Report

415601114-10-22-2025-14-AS-ACON-DNHVDN-20251117152100

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN BRUNO RO , 851 TRAEGER AVE., SUITE 360

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

10/09/2025 and conducted by Evaluator Komal Curley

COMPLAINT CONTROL NUMBER: 14-AS-20251009094007

Regional Operations Specialist, Tammie Sampedro

Staff did not ensure reporting requirements were followed

On October 22, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Regional Operations Specialist, Tammie Sampedro and explained the purpose of the visit.

Regarding the allegation, staff did not ensure reporting requirements were following, according to the reporting party, after the alleged abuse incident that occurred on 10/3/25, the facility did not submit an incident report (LIC624) to CCLD and did not submit an APS report.

Based on records reviewed and staff interviewed, there were no incident reports submitted to CCLD regarding the alleged abuse incident that occurred on 10/3/25. The facility was unable to provide any documentation to show that an incident report or an SOC341 was submitted to CCLD.

Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Regional Operations Specialist, Tammie Sampedro and a copy is provided.