Complaint Investigation Report

A Case Management visit was conducted on 8/29/25 regarding this incident and citations were given. This new allegation is to investigate additional concerns regarding C1’s care. Following the incident, records state that Staff 4 (S4), and the administrator assessed C1 and determined that no injuries were present, so C1 was not taken to the hospital.

Records state that C1 has a history of seizures, one occurring on 5/8/25 per an incident report provided to Community Care Licensing. Despite this known medical history, staff did not arrange for a medical evaluation immediately after or in the following days of the incident on 8/24/25.

During the investigation, an additional incident was identified involving Client 2 (C2). Documentation shows that C2 developed skin rash on their left arm, it was first documented/noticed on 09/16/25 on the daily progress notes, it was also reported via an incident report by the facility, stating first noticed on 9/16/25. Documents state that the day it was discovered administrator tried to schedule an appointment, but none were available until an original appointment date of 10/8/25. Interview with administrator, the facility began treating the rash with a first aid ointment. The daily progress notes show 3 areas of concern on C2’s left arm, C2 continued to pick at the affected areas over the next 9 days, medical treatment was obtained on 09/25/25. It was documented on an incident report that doctor stated C2 was picking at the skin due to itching.

Due to the behaviors and service plans of clients in care, continual items that cause agitation such as picking or itching can lead to behaviors and injuries. Clients in care of facility cannot all verbalize their injuries or pain, therefore the need to have a medical professional examine them after incidents is necessary as the facility is not a medical facility and cannot determine those conditions.

Based on interviews and records obtained there is sufficient evidence that the allegations that the facility did not seek timely medical attention or provide appropriate follow-up care placed residents at risk and therefore is substantiated.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Continued on 9099-C