Complaint Investigation Report

486803987-7-18-2025-21-AS-KMOA-DK2RTV-20250729131859

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SANTA ROSA RO , 1450 NEOTOMAS AVENUE, STE. 100

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

06/17/2025 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20250617093603

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced and met with Administrator Jean Rice to deliver findings of a complaint investigation-initiated June 17, 2025. During the course of this investigation, outside records were reviewed, observations were made, and interviews conducted. Complaint alleges staff did not seek timely medical care due to staff (S1) not contacting emergency personnel upon the death of Resident (R1). Upon S1 finding R1 unresponsive, S1 did not call emergency personnel, but contacted the Administrator who informed S1 to contact R1’s family and the mortuary be contacted. R1 was not on hospice. S1 is not qualified to pronounce a resident deceased and did not follow the proper procedure to contact 911. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation staff did not seek timely medical care is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Jean Rice and Appeal rights were given.

The Regional office will be conducting a Non-compliance Conference with Licensee, time and date to be determined.