Complaint Investigation Report

(Continued from LIC9099) At approximately 10:21 a.m., LPA Rios conducted a physical plant tour of the facility. During the tour, LPA observed that R1 was not in the facility, Resident #2 (R2) and Resident #3 (R3) were asleep. No health or safety issues were observed at this time. Prior to today’s visit, LPA Rios conducted telephone interviews with R1’s responsible person and R1’s assigned Licensed Clinical Social Worker (LCSW), who is assisting with R1’s placement.

Allegation: Unlawful eviction. It was alleged that the facility would not be accepting R1 after hospital discharge. To investigate this allegation, LPA conducted an interview with the Licensee and was informed that they had spoken to R1's LCSW sometime last week regarding R1's discharge and return to the facility. The Licensee confirmed they informed R1's LCSW that upon discharge they would not be admitting R1 due to R1's "unstageable" wounds and that she could not admit R1 because they were not allowed to take care of someone with "unstageable" wounds per Community Care Licensing (CCL). LPA's review of R1's Home Health services for wound care confirmed R1 had been receiving care for a wounds since 05/22/25 after being admitted to the facility on 04/12/25. On 08/11/25, an unannounced Case Management – Deficiencies visit was conducted. During the visit, the facility was cited for retaining R1, who had a prohibited health condition. As part of the plan of correction, the Licensee submitted an exception request to retain R1 at the facility. Licensee had not received a approval or denial from CCL. Upon LPA’s request, the Licensee could not provide R1's re appraisal regarding changes in the level of care. Additionally, the investigation revealed the Licensee did not serve R1 or their responsible person a written 30-day Eviction notice.

On 09/17/25, a telephonic interview with R1's responsible person revealed that they had anticipated R1 going back, and had conversations with the licensee about making their monthly payment on 09/14/25 however, on the 09/16/25, R1's LCSW informed R1's reasonable person that the Licensee stated R1 requires a higher level of care. No re-appraisal and no conversation with R1's responsible person was done by the facility's Licensee to inform that the facility can no longer meet R1's needs. On 09/17/25, a telephonic interview with R1's, LCSW revealed they had made contact with the licensee to arrange R1's return when the Licensee informed them they would not be taking R1 back due to R1's Stage 3 wound and Licensing. Licensee also asked the LCSW to help with placement. Based on interviews and record review this allegation is Substantiated at this time.