Complaint Investigation Report

547208243-8-4-2023-24-AS-MHON-CUZL5M-20230824082722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

05/31/2023 and conducted by Evaluator Melinda Medina

COMPLAINT CONTROL NUMBER: 24-AS-20230531092050

Facility did not report incidents to licensing

On 8/04/23, Licensing Program Analyst (LPA) M. Medina and Licensing Program Manager (LPM) M. Hoffmann conducted a subsequent visit to deliver findings to complaint. LPA and LPM met with Laura Li, Chief Administrative Officer.

During the investigation, LPA conducted interviews and reviewed records and based on review, the allegation that facility does not follow reporting requirements is SUBSTANTIATED. Facility did not submit incident reports within 7 days for an incident involving R1 that occurred on 5/2/23. It was not submitted until 5/13/23; Incidents involving R2 occurred on 5/29 however an incident report was not submitted until 6/13/23. An incident involving R3 occurred on 6/1/23 however an incident report was not submitted until 6/13/23. This poses a potential risk to the health, safety, or personal rights of residents in care.

Deficiency cited in the attached 9099D for violation of Title 22, Division 6, Chapter 1, Article 06. Appeal rights provided, and exit interview conducted with Chief Administrative Officer.