Complaint Investigation Report

455002695-10-13-2025-59-AS-TORZ-DMG6FV-20251014204658

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

07/15/2025 and conducted by Evaluator Ivan Avila

COMPLAINT CONTROL NUMBER: 59-AS-20250715082743

Staff does not treat residents with dignity/respect

On October 13, 2025, Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA Avila met with Grace Puckett and explained the purpose of the visit.

During the investigation process, interviews and a review of records were initiated.

LPA investigated the allegation, “Staff does not treat residents with dignity/respect.” Based on documentation provided and interviews conducted, interviews stated S1 was recently hired and needed more training on how to address residents and their care needs. Staff made management aware of S1 making inappropriate comments about residents to other staff. S1 did not directly make comments to residents. Facility addressed the staff concerns and scheduled S1 for additional training and removed S1 from the schedule.

Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. Findings that the complaint is Unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted, and a copy of the report was provided.