Complaint Investigation Report

Regarding the allegation that staff did not seek timely medical care for resident, medical records revealed that R1 was diagnosed with cancer that resulted in an “incurable” wound that would continue to leak. Additional records reviewed revealed that the facility submitted a report to the Department which indicated a nurse from an outside agency noted the wound “may be getting infected” on 6/3/25. Facility staff did not address this concern and it wasn’t until the next day 6/4/25 that R1’s outpatient program sent R1 to the hospital for a wound check.

Regarding the allegation that staff did not ensure residents wound care needs were met, records reviewed revealed that R1 was receiving home health care services daily for wound care treatment. Per oncology notes dated 6/6/25, the wound required changing 3-4 times daily due to “odor and weeping”. Facility staff reported that R1’s insurance would not cover these changes. It wasn’t until 6/14/25 that R1’s oncologist was consulted by facility staff and were advised to take R1 to the hospital and R1 should be in a skilled nursing facility.

Regarding the allegation that staff did not ensure resident's hygiene needs were met, a review of R1’s most recent Physician’s Report (LIC602) dated 6/29/24 revealed that R1 was assessed as capable for self-care, including bathing and grooming. However, the LIC602 had not been updated since R1 received a cancer diagnosis. Staff reported the wound was malodorous and causing clothes to be ruined due to constant leaking. Interviews with facility staff reported that R1 wanted to continue going to their outpatient program and observed it kept R1 in high spirits. Staff reported not wanting to deny R1 their right to attend their program. However, due to the nature of R1’s wound, the leakage was unmanageable and per outside source, would soil R1’s clothes.

The Department has investigated the above mentioned allegations. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was met to support or corroborate these allegations and therefore deemed substantiated. Three deficiencies are being cited per Title 22 California Code of Regulations (please refer to 9099-D pages).

An exit interview was conducted with House Manager Stella Quintero and Relief Staff Micaela Truong, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.