California Deemed Inadequate in Investigating 11,000 Nursing Home Complaints

California’s Department of Public Health has failed to effectively investigate nursing home complaints, according to a state audit that notes there are 11,000 unresolved complaints and reported incidents in its system.

What’s more, many of these complaints and incidents have remained open for nearly a year on average, with the average number of days open ranging from 14 to 1,042 days.

The department, which is responsible for monitoring more than 2,500 nursing homes, classified more than 40% of these complaints and incidents as having caused or being likely to cause harm to a resident.


For example, the Santa Rosa-Redwood Coast district office prioritized 102 open complaints and entity-reported incidents (ERIs) related to facilities as “immediate jeopardy” — indicating a situation that poses a threat to an individual’s life or health. These complaints and ERIs had remained open for an average duration of almost a year.

“By not ensuring that all complaints and ERIs are processed promptly, Public Health is placing at risk the well‑being of residents of long‑term health care facilities,” the audit states.

In California, complaints related to long‑term health care facilities are investigated by the 15 district offices of Public Health’s Licensing and Certification Division (licensing division), which include a contractor and the licensing division’s State Facilities Unit. These entities also investigate ERIs. The Professional Certification Branch (PCB) within the licensing division is responsible for investigating complaints against certified individuals.


But the Department of Public Health does not provide adequate oversight of complaint processing by the district offices or the PCB, the audit finds.

Until late 2013, when it established a tracking log of open complaints and ERIs, Public Health did not have a standardized method for monitoring the status of open complaints and ERIs at the district offices and for assessing whether these complaints were being addressed promptly.

In addition, PCB lacks accurate data about the status of investigations into complaints against individuals, and this deficiency prevents management from providing proper oversight and monitoring of complaint handling, the audit finds.

“It’s a scathing report, really. The system is in place, but it’s not functioning,” Carole Herman, president of the Sacramento-based Foundation Aiding the Elderly, tells The Sacramento Bee. “And no one who is high up in the agency is being held accountable for it.”

To access the audit, click here.

Written by Emily Study