Complaint Investigation Report

Two out of four staff interviews conducted revealed that when R1 is with their spouse in assisted living and R1 has an incontinence episode, assisted living staff will call memory care staff and tell them they need to assist R1 with incontinence care. Per R1s Needs and Service plan under care notes, assisted living staff are to provide care during the day as needed to R1. Under Bladder Incontinence in R1s Needs and Service Plan, states resident will receive assistance with incontinence care as needed and staff will provide physical assistance to changed soiled brief and clothing. During the investigation LPA was provided with additional evidence that R1 pressed their pendant button for assistance around midnight on 08/24/2025 with no answer. Document review of R1s alarm response report shows R1 called for assistance at 11:40PM on 08/24/2025 and didn’t receive assistance until 12:28AM on 08/25/2025, a total of 47 minutes.

Allegation, staff do not ensure that resident has clean bedding, based on interviews that were conducted with facility staff and outside parties, and records reviewed, it was determined R1s previous mattress was found to be saturated in urine. Interviews conducted with outside party revealed they have observed R1s mattress to be saturated in urine multiple times. Interviews conducted with 2 of 5 staff revealed R1s mattress was saturated in urine along with a urine smell before getting discarded. Record review show R1 received a new mattress on 07/07/2025.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given.