Complaint Investigation Report

Interviews with staff revealed that staff are aware of the responsibilities of resident care regarding incontinence. Staff 1 (S1) stated that “care staff will perform the checks every two hours, we have rounds with residents in rooms.”

Interviews with residents revealed that Resident 1 (R1) may not receive incontinent care that matches their needs. R1 stated that “Staff put a diaper on me because most of the time they don’t check on me. I can go to the bathroom by myself; I just can't transfer to my chair myself because I'm not strong enough.” R1 continued by stating they have experienced times when they were assisted by staff to go to use the toilet, but staff did not come back to assist R1 out of the bathroom when they used the signal system.

Interviews with Outside Sources revealed parts of the incontinent care provided by staff that are not meeting the needs of R1. Outside Source 2 (OS2) told the LPA there were times when R1 was not cleaned properly after receiving care from the facility. Outside Source 3 (OS3) stated while taking care of R1’s incontinence needs, they noticed that care staff did not properly clean R1. OS3 told the LPA that there was a time when they were taking care of R1 that they discovered feces in R1's genitals due to the care the facility staff provided.

Records review revealed that in a pre-placement appraisal dated May 2025, under the “Services Needed” section, it is indicated that R1 needs continence care. In a medical assessment dated October 2025, R1’s report under the “Overall Physical Health” section shows that R1 does not require care for Bowel or Bladder incontinence, however there is a note saying that they wear briefs for accidents; this corroborates resident interviews.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with ED Mike McCoy, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.