Complaint Investigation Report

455002976-9-21-2023-59-AS-KHOS-CW2HTD-20230926062834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO NORTH ASC , 9835 GOETHE ROAD, SUITE 100

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

07/28/2023 and conducted by Evaluator Ivan Avila

COMPLAINT CONTROL NUMBER: 59-AS-20230728163040

Staff do not properly supervise resident, resulting in resident awoling from the facility.

Staff did not monitor resident for change in condition.

This document has been amended on 09/21/2023 to reflect the appropriate deficiencies LPA Avila observed during the investigation that was previously recorded on 09/07/2023. LPA made an unannounced complaint investigation visit at this facility and met with Amber Greene.

On 04/26/2023 R1 exited the facility alone and was found later by staff. LPA interviewed staff and they stated R1 had walked out of the facility and was found some time after. On 04/28/2023 R1 exited the facility alone again and was found at the corner of the block. LPA interviewed Facility Manager (S1) and S1 stated that R1 was missing for approximately 20 to 30 minutes.

LPA interviewed staff and reviewed documents indicating that the Needs and Service plan for R1 was not updated to reflect R1s change of condition in leaving the facility alone and unassisted on 04/26/2023 and 04/28/2023.Based on LPAs interviews which were conducted and record reviews, the preponderance of

evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations Title 22 and or the California Health and Safety Code are being cited on the attached LIC 9099D and copy of report and appeal rights were provided to Amber Greene.