Complaint Investigation Report

Regarding the allegation,"Staff did not prevent resident from developing a pressure injury" it is being alleged that staff did not rotate a resident (R1) while in care. Record reviews revealed the following: On 04/29/2025, R1 was noted with a Stage I pressure injury to their coccyx. Home Health advised the facility caregivers how to clean and apply the topical ointment to the area when R1’s adult brief is changed or when they (are) toileted. On 06/09/2025, R1 was noted with an additional pressure injury, Stage I, on their sacrum. On 06/16/2025, a physical therapy evaluation was conducted by the home health agency for R1. A wound to R1's right leg was discovered. On 06/19/2025, an additional Stage II pressure injury was discovered to R1's sacral area. On 06/26/2025, a third Stage II pressure injury was discovered on R1's sacrum. On 07/02/2025, home health noted the pressure injury had exacerbated to a Stage III. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

Regarding the allegation, "Staff did not notify resident's family of change in condition" it is being alleged that the facility staff did not notify their responsible person of a change in condition. Record reviews revealed the following: From 07/04/25 through 07/16/25 there is mention of a wound from the responsible person, related to R1's current condition. Record reviews from 06/01/25 through 07/04/25 does not indicate wounds have been discovered by home health agency, despite the fact that new wounds have been indicated via home health record and that caregivers had been informed to notify a resident's (R1) of any change in condition on 06/02/25, 06/09/25, 06/16/25, 06/19/25 and 06/26/25. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

There have been two (2) deficiencies cited during today's visit. An immediate civil penalty of $500.00 is being assessed. Please see LIC421IM.

At this time, an additional civil penalty determination is pending in reference to The Welfare and Institutions Code Section 15610.67 which defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

An exit interview was held and plans of corrections were developed with current Administrator, Brenda Hernandez, and a copy of this report and appeals rights have been provided.