Complaint Investigation Report

502701180-7-14-2026-27-AS-LKIG-DW9UBY-20260723152707

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

06/15/2026 and conducted by Evaluator Noel Wolf Petersen

COMPLAINT CONTROL NUMBER: 27-AS-20260615110219

Facility did not provide appropriate care and supervision resulting in a harm/injury

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility unannounced to investigate a complaint investigation with the above allegation, LPA met with Executive Director Jackie Hernandez to discuss the findings.

Specificly a large but first degree burn via some heated juice. In interview, the staff S1 reported that they had heated a prune juice and left it with the client. Record review of 602 for R1 indicates he has dementia and assistance with feeding. Administrator provided that the staff had recived a generalized training as a result of the incident about providing the clients with heated fluids. LPA asked for a log of the training.

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(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.

A citation was issued, a copy of the report was read and given to the administrator, appeal rights were provided. exit interview was conducted.