Complaint Investigation Report

HA submitted a lab work for R1 on 10/21/24 and results on 10/22/24 revealed R1 was positive for UTI. HA stated that a clogged catheter, no urine output, and no intake could contribute to a UTI.

When ADM was interviewed, ADM mentioned not remembering calling hospice. One staff member (S1), confirmed that they observed a clogged catheter and reported it to the ADM.

The ADM neglected and/or failed to seek medical services for R1 when ADM acknowledged that R1 had a clogged catheter, with no urine output for 24 hours; and when R1s change of condition was observed. ADMs neglect and failure to seek immediate care for R1 resulted in R1s UTI.

At the time of the complaint inspection on 02/23/2026, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An Immediate Civil Penalty of $500.00 was also assessed (refer to the LIC421-IM page). An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Caregiver Jesus Arenas, whose signature below confirms receipt of these rights.