Complaint Investigation Report

577005341-4-28-2022-21-AS-KMOA-CEZPB5-20220602110945

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

01/27/2022 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20220127102600

Licensing Program Analysts (LPAs) Jill Nakagawa and Chris Arnhold arrived unannounced and met with Miriam Faris, Administrator to continue this complaint investigation and deliver findings. During the course of this investigation, the facility was toured, records were reviewed, and interviews conducted.

The above allegation alleges that a resident had a fall resulting in injury then passed away. LPA reviewed resident records and found that, although resident did suffer two falls over the course of 5 days, EMS and Hospice agencies were contacted at the time and assessed the resident. The evaluation resulted in resident not being transported to the hospital for care or treatment. Review of the Death Certificate show the cause of death was not related or a result of the fall.

This agency has investigated the complaint alleging Questionable Death. We have found that the complaint

was unfounded, meaning that the allegation was false, could not have happened