Complaint Investigation Report

496803825-1-29-2026-21-AS-VBEI-DQYNJS-20260204093048

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

11/13/2025 and conducted by Evaluator Robert Frank

COMPLAINT CONTROL NUMBER: 21-AS-20251113161000

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with facility Executive Director Carla Lua.

During the course of the investigation LPA conducted a facility visit, conducted interviews, collected and reviewed documents. Complaint alleges facility left a resident at the hospital. On 11/13/2025 resident R1 was transported to Healdsburg Providence Hospital Emergency Center. When the hospital contacted the facility to arrange discharging R1 back to the facility a witness states that a staff member at the facility stated, “we will not be taking the patient back and we are on the phone with the State right now. You guys have to keep them.” Witnesses stated that in a later conversation, a staff member of the facility stated, “facility will accept the patient back if they are prescribed medication.” Later in the same day (11/13/2025) resident R1 was transported back to the facility. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy of report discussed and provided to Executive Director Lua. Signature on form confirms receipt of documents.