Complaint Investigation Report

Allegation: Staff did not assist resident with incontinence care needs in a timely manner

During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that on 07/23/25, RP called POA on his phone around 7:45 AM asking for help because his clothing and bedding were soaking wet and that staff was not responding to his calls (ringing his bell).

Staff (S1) confirmed with LPA that they failed to assist R1 timely with his incontinence care needs because the other staff (S2) did not show up for her scheduled work at 6AM that day. LPA also interviewed R1 who stated that another staff (S3) changed his wet clothing, diaper and bedding around 9AM on 07/23/25 since S2 did not arrive at the facility until 10AM.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not assist resident with incontinence care needs in a timely manner was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties .

Exit interview conducted. Appeal Rights and a copy of this report provided.