Complaint Investigation Report

490108916-7-21-2026-21-AS-BMOS-DW8VAS-20260722161626

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

06/16/2026 and conducted by Evaluator Marisol Cuadra

COMPLAINT CONTROL NUMBER: 21-AS-20260616081156

-Staff are not meeting residents' medical needs.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to delivered findings regarding the allegation listed above and met with Lora Navarro, Administrator.

The Department received an allegation of staff are not meeting residents' medical needs. The Reporting Party raised concerns that facility staff are resistant to most care outside of regular appointments, but finally starting to get preventive screenings completed, but it was noticed that the facility is not monitoring blood pressure at home for clients in care who has a medical condition. Based on records review, the facility provided proof that all clients in care have seen their physician and got preventive screenings completed regularly. However, during records review, it was revealed through interviews with administrator that clients (C1, C2, C3 & C4) had a doctor’s order in place on 3/13/26 to pick up a blood pressure monitor to monitor clients’ blood pressure due to elevated blood pressure readings, but the facility did not pick up the monitor until 6/16/26 to initiate monitoring of all clients’ blood pressure as instructed by C1’s physician. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.