Complaint Investigation Report

486803653-2-11-2025-21-AS-KMOA-DE9NB4-20250226091831

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1450 NEOTOMAS AVENUE, STE. 100

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

11/07/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20241107150613

Staff retained a resident that has a prohibited health condition

Staff did not ensure facility was free from pests

Medications not administered as prescribed

Staff are not properly trained to use a hoyer lift

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. This investigation included 5 unannounced site visits; a review of documents and statements from staff and witnesses. It is alleged Resident (R1) has a prohibited health condition. Although R1 has a stage 3 wound, R1 is on Hospice which is allowed by regulation. The facility has had a bed bug infestation first apparent in October of 2024. Facility management and housekeeping staff have followed the CA Dept of Public Health guidelines and have employed professional exterminators on a continuous basis throughout the period bed bugs have been present. This Agency has inspected for rodents on site visits conducted on 11/19/24; 12/03/24; and 01/28/2025 with negative results. An audit conducted on 12/17/2024 indicated medications were properly stored and being administered as prescribed. Initially, a Hoyer lift was obtained for Resident (R2) but was not used by staff at the request of R2's family. In service training on Hoyer lift was scheduled for staff but cancelled when it was determined the lift would not be used. Although the allegations may be true, based on observation, records and statements, there is not a preponderance of evidence to prove or disprove the allegations. Therefore, the complaint is UNSUBSTANTIATED.