Complaint Investigation Report

502700869-10-1-2024-27-AS-LRIS-DDJNST-20250203094333

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO SOUTH ASC , 9835 GOETHE ROAD, SUITE 100

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

09/30/2024 and conducted by Evaluator Arielle Pascua

COMPLAINT CONTROL NUMBER: 27-AS-20240930172435

Staff did not keep the facility free of cockroaches

On 10/01/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Jennifer Whitely and explained the purpose of the visit. The purpose of this visit was to inform the facility and it's representative that a complaint has been filed against it at this time.

Current census was 35. A tour of the facility was conducted. A brief interview with FDA Whitely was conducted.

LPA conducted a tour of the facility, 4 resident bedrooms, and the kitchen. In bedroom 1, LPA observed 1 small brown cockroach on the side of the wall, 2 behind the resident bed, and 1 in the corner of the room. A interview with 3 staff was conducted and it was learned that they have seen or have reported small brown cockroaches to the maintenance director around 2 weeks ago.

Based on the observations made during today's visit, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, appeals rights and a copy of the report was given end the of this visit.