Complaint Investigation Report

275202817-12-15-2024-24-AS-BCHN-DCG3N6-20241230172323

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

07/25/2024 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20240725145545

Due to neglect, resident sustained stage 4 pressure ulcers.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above . LPA met with facility Administrator, Maria Perez and explained the purpose of today's visit.

Regaring the allegation Due to neglect, resident sustained stage 4 pressure ulcers. Resident 1's Progress Notes document on 07/14/2024 redness and open sore on bottom. Resident 1 was re assesed by the facility nurse on 07/14/2024. Resident 1's Progress Notes document they were to be admitted to home health .Resident 1 was seen by Home health staff on 07/17/2024 and sent to the local emergency room. Resident 1's was admitted to the emergency room on 07/17/2024 with a stage 4 sacrococcyged wound. Based on documents reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Executive Director Maria Perez, and a copy of this report along with appeals rights provided.