Complaint Investigation Report

In regard to the allegation” Staff do not ensure that resident has clean bedding”, It is alleged that R1’s bedding had urine on it and staff refused to change bedding. During interview with Administrator, and staff six (6) out of six (6) stated that bedding is cleaned once a week or as needed. During initial visit on 11/06/2025 LPA observed R1’s bedding stained with urine. R1 stated to Administrator that he/she had asked the night before for linen to be changed and Administrator stated staff would be there today at 3:00 PM to change it. During visit on 11/18/2025 LPA observed room 9 and room 17 to have urine-stained bedding. Interviews with residents, four (4) out of seven (7) stated that they have had urine-stained bedding or witnessed other residents with soiled linen. R1 stated that they are supposed to change bedding weekly but get too busy to do it. R7 stated one time they had an accident and when staff was asked to change sheets, they stated that it’s not my job wait till another staff gets here, forcing S7 to wait till the next day.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Andrea Flores.