Complaint Investigation Report

Allegation : Facility staff did not provide communication with authorized representative.

It was alleged that the facility failed to communicate with the authorized representative regarding the resident’s care and condition.

On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated not being aware of any concerns. A1 stated multiple staff communicate with families as needed.

On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 7 out of 7 staff denied the allegation and stated they would refer the representative to the Administrator, med tech, or front desk.

On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 8 of out 10 residents denied the allegation and expressed no concerns with communication. Several residents independently manage their own communication or do not have family. 2 out of 10 residents did not confirm nor deny the allegation and mentioned having no family (R8) and or does not communicate with their family (R4).

On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the following: R1 has a POA, according to a document titled Power of Attorney for California (dated on 05/11/2024). This POA is also mentioned on the LIC 601 has the person responsible for final affairs, payment for care and legal guardian if any and this is also indicated on LIC 603 that POA is the person who manages R1’s finances.

On 07/07/2026 between 11:45am – 1:00pm, the Department conducted further review of four (4) internal resident incident reports dated (2) on 07/08/2025, 11/23/2025, and 01/21/2026. The incident report dated 07/08/2025 documented that R1 was sent to the hospital and the written narrative stated that the POA was notified; however, the “Responsible Party” section reflected “No” for contact made. The incident report dated 07/08/2025 documented R1’s return from the hospital and indicated that discharge paperwork was scanned to GPDocs, the pharmacy, and the former office desk manager, and that the POA was notified; however, the “Responsible Party” section again reflected “No” for contact made. The incident reports dated on 10/11/2025 of an unwitnessed fall, on 11/23/2025 R1 screaming and shaking and on 01/21/2026 documented a witnessed fall in which 911 was called; however, the “Responsible Party” section reflected “No” for contact made. Based on the 4 incident reports, the Department observed that “No” was consistently checked for contact made to the responsible party, indicating that the authorized representative was not contacted at the time of each incident. The Department did not observe supplemental documentation indicating that communication occurred outside of the incident reports.