Complaint Investigation Report

It is alleged that resident #1 (R1) was illegally evicted from this facility. The complainant reported (R1) was admitted at Kaiser Permanente on 06/12/24 due to concerns with wounds. (R1) was evaluated, treated, and deemed safe for discharge. (R1) was not found to require a higher level of care. The hospital wound care specialist and Registered Nurse determined no infection, and the wounds were not open and appeared to be healing. The complainant reported the administrator declined to accept (R1) back to the facility and stated (R1) required a higher level of care due to the wounds.

According to resident #1 (R1)’s Admissions Agreement (dated: 08/10/23), (R1) was admitted to Santa Fe Home Care effective 08/10/23. Physicians Report LIC 624A (dated: 08/30/23) is non-ambulatory unable to self-care and requires assistance with assisted daily living (ADL). (R1) was under home health care for wound care with Human Touch Home Health Care from (May 2023 through October 2023).

An Unusual Incident Report LIC 624 (dated: 06/17/24) indicated nurse from Quality Home Health reported that (R1) has a bed sore and recommended that (R1) be evaluated at the hospital due to the bed sore and high level of care. (R1) was transported and admitted to Kaiser Permanente Medical Center Emergency Department on 06/12/24 for a wound problem. Kaiser Permanente medical records (dated: 06/19/24) revealed that sores were cleaned and treated with no indication of Stage 3 or 4 pressure injuries that are classified as a prohibited health condition and that (R1) would require a higher level of care. (R1) was authorized discharge with home health assistance by the hospital.

Investigation revealed (R1) was discharged on 06/14/24 from the hospital and was admitted to Golden Senior Assisted Living II and not Santa Fe Care Homes. (R1) was admitted to Golden Senior Assisted Living II on 06/14/24. On 06/17/24, (R1) was transported and readmitted to Kaiser Permanente Medical Center Emergency Department and has remained at the hospital waiting for discharge.

On 06/17/24 between 03:00 pm – 03:14 pm, the Department interviewed resident #1 (R1) verified being admitted at Golden Assisted Living and not Santa Fe where (R1) preferred to reside.