Complaint Investigation Report

During the course of this investigation, Edward Hector (Department of Social Services Community Care Licensing Investigation Branch) obtained medical records from various health care agencies and interviewed Staff #1 (S-1) and Staff #2 (S-2). C-1 was unable to be interviewed as C-1 is non-verbal. Additionally, San Gabriel Pomona Regional Center also issued a Corrective Action Plan (CAP) on 03/13/25 for the above allegations. Per Facility Administrator, San Gabriel Pomona Regional Center has cleared the CAP as the Facility Administrator has complied with the CAP requirements. Facility Administrator provided a copy of the CAP clearance letter dated 09/03/25.

Allegation: Facility failed to seek timely medical care. It has been alleged that staff did not seek timely medical care for C-1’s. Per medical records obtained (by Investigator Hector) from various health care agencies, C-1 sustained an ankle fracture and received medical treatment (on 11/19/24) which included bandages of C-1’s ankle. C-1 bandages were not taken off and the skin was not checked for the period of 11/19/24 to 12/19/24. When the bandages were removed, C-1 was discovered to have a non-pressure decubitus ulcer. Facility staff first discovered C-1’s wound on 12/19/2024, and described the wound as being able to see C-1’s "tendon”(Stage 4 / Unstageable). The Facility Administrator admitted to not seeing C-1’s wound when the staff first discovered the wound. Facility staff and Facility Administrator requested C-1 to receive home health services, but it was not approved until 01/10/25. Medical records and interviews corroborate this allegation.

Allegation: Facility retained a resident with a prohibited health condition. It has been alleged that C-1 was retained at this facility with a prohibited health condition. The facility staff first discovered C-1’s wound on 12/19/24, and described the wound as being able to see the C-1’s "tendon”(Stage 4 / Unstageable). The Facility Administrator admitted to not seeing C-1’s wound when the staff first discovered the wound nor did the Facility Administrator request a waiver to retain C-1 at this facility with a prohibited condition. The Facility Administrator indicated that if the Facility Administrator would have seen the wound, the Facility Administrator would have sent C-1 to a Skilled Nursing Facility. Medical records and interviews corroborate this allegation.

Allegation: Facility did not report residents change in condition. It has alleged that facility staff did not report C-1’s change in condition. Facility Administrator admitted to not reporting C-1’s change in condition. Facility Administrator admission to not reporting C-1’s change in condition corroborates this allegation.

Refer to LIC 9099C for the continuation of this report.