Complaint Investigation Report

Facility medical records. Six of six individuals interviewed confirmed the facility did not seek medical care in a timely manner for C1. Administrator Jon Castro further confirmed an Incident Report was never submitted to Licensing nor the RCOC when C1 was sent out to the hospital.

C1 was sent out to HHN Hoag Hospital Newport Beach on December 31, 2022 and admitted at 6:23 PM with lethargy and weakness. C1 was intubated and found to have Osteomyelitis of the right foot and Sepsis. C1 underwent surgery requiring a partial amputation of their right foot. C1 remained hospitalized for 9 days and upon discharge from HHN Hoag Hospital Newport Beach was transferred to Pelican Ridge Post Acute Skilled Nursing Facility for further rehabilitation. As of today's date, C1 has not returned to the facility.

Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Facility failed to seek medical care in a timely manner resulting in serious injury and Facility failed to report the incident to Licensing are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 are being cited on the attached LIC 9099D. A Civil Penalty was also issued.

An exit interview was conducted with Administrator Jon Castro and a copy of this report along with the appeal rights, LIC 811, LIC 421IM, and LIC 9098 were provided at the time of this visit. Due to technical issues LPA Velazquez was not able to print the report at the time of the visit and Administrator Jon Castro agreed to receive the report via email.