Complaint Investigation Report

079200309-9-28-2023-15-AS-HHUL-CWRVEH-20231019162222

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1515 CLAY STREET, STE. 310

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

06/26/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20230626160238

Resident sustained unstageable pressure injuries due to staff neglect

On 9/28/2023 at 2:15 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Administrator Telesha Clarke.

During the complaint visit LPA obtained information, reviewed records, collected documents, and interviewed staff. It was alleged a resident sustained an unstageable pressure injury while in care. During an interview with S1 they stated that they did have a resident who had a pressure injury during that time frame. This resident was on hospice when the ulcer developed and was being addressed in the hospice care plan that the facility was following.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.