Complaint Investigation Report

157209207-2-10-2025-24-AS-SPIY-DDRUTB-20250210145137

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

10/16/2024 and conducted by Evaluator Rachel A Bruce

COMPLAINT CONTROL NUMBER: 24-AS-20241016233013

Staff allow a resident to be soiled for extended periods of time

Licensing Program Analyst (LPA) Rachel Bruce conducted the subsequent complaint investigation visit to the facility for the purpose of delivering the finding on the above allegation that staff would allow a resident to be soiled for extended periods of time.

During the course of this complaint investigation LPA interviewed staff on duty, outside parties, and obtained and reviewed facility records. It was determined based on the interviews, observations, and records review that the above allegation is SUBSTANTIATED. Facility staff did leave patient soiled for extensive periods of time because the resident did not want her diaper changed. Based on the LPAs investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report and appeal rights will be provided via email.