Complaint Investigation Report

306004779-8-20-2021-22-AS-SSAS-C9D2J9-20211203162557

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 770 THE CITY DR., SUITE 7100

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

09/04/2020 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20200904122808

Resident sustained a pressure injury while in care.

Facility refused medical services for resident in care.

Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of the complaint investigation. Upon arrival, LPA met with Administrator Maricel Lindsey. The investigation consisted of interviews with Administrator and witnesses as well as documentation. The following was determined:

Resident #1 was admitted into the facility in October 2016. Records reviewed disclosed that R1 developed a Stage 1 pressure injury and was referred to home health on 7/6/20 by her medical provider. Home Health visited R1 at the facility in September. According to staff interviewed, R1 has had Health Services several times since 7/20/2020 for wound care and physcial.

Based upon interviews and a review of records, the allegations above are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that R1 developed a Stage 1 pressure injury due to neglect or that the facility staff refused medical services. Licensee is reminded that residents shall always receive care as ordered by their doctor.

An exit interview was conducted and a copy of this report was provided to Maricel Lindsey.