Complaint Investigation Report

486803822-6-2-2026-21-AS-KMOA-DVLLD3-20260702083915

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

05/27/2026 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20260527160543

Staff did not provide resident's records to responsible person

On 06/02/2026, Licensing Program Analyst (LPA) Nakagawa and Licensing Program Manager (LPM) Mota arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation. LPA and LPM met with Kristine Hiquiana, current Administrator (who was not in place at the time of incident) to discuss findings.

The complaint alleges that Staff did not provide resident's (R1) records to responsible person. It is alleged that responsible parties were not provided the Incident Report for 10/27/2024. A review of the Incident Report submitted to the Dept. does not indicate that staff provided a copy to the responsible parties therefore the allegation that Staff did not provide resident's records to responsible person is substantiated. (See 9099-D).

Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.