Complaint Investigation Report

These symptoms included pronounced lethargy, incoherent speech, an inability to complete a routine walk, and a noticeable decrease in appetite, all of which went unaddressed by facility personnel at the time.

Facility staff reported to department Staff that they did not observe a change in Resident #1’s condition until October 1, 2025, when the resident failed to get out of bed. Although the facility notified the family that day, it was the family who, upon arrival and observation of the resident’s decline, insisted on an immediate hospital transfer. Resident #1 was subsequently admitted to Park view Community Hospital suffering from a blood sugar level in the 600s, diabetic ketoacidosis, and hyperglycemia. The clinical evaluation further revealed hemodynamic instability, altered mental status, dehydration, and severe electrolyte imbalances, including hypokalemia, hyperkalemia, and hypernatremia. Staff indicated that R1’s diabetes was controlled by diabetic medication. However, there was no documentation or formal orders showing why the medication was discontinued on July 13, 2025.

Based on the evidence the allegation that Staff did not seek medical attention to resident#1 resulting in hospitalization due to neglect/lack of care and supervision is Substantiated . A substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met.

California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D). An Immediate civil penalty for a violation has been assessed in the amount of $500.00.

An exit interview was conducted where reports (LIC9099, LIC9099-C & LIC9099-D) LIC 421BG (6/17) and Appeal Rights were discussed and provided to Wellness Director Victoria Ong, Facility representative at the conclusion of the visit.