Complaint Investigation Report

496803337-11-3-2022-21-AS-CMAZ-CL2MX8-20221110085932

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

10/25/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20221025120741

Staff not fingerprint cleared and/or associated.

Licensing Program Analyst Leibert arrived unannounced for the purpose of opening the investigation of this complaint. LPA was meet by caregiver and toured the facility. At the time of the visit, five resients and one caregiver were present. LPA determined that caregiver, S1, is not associated to facility. Based upon statements and record review, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.