Complaint Investigation Report

On 3/18/2025 the CCLD RO received an additional complaint regarding R1’s care at the facility with the control number 29-AS-20250318102817. Investigator Jaurequi investigated allegations of both complaints during the investigation.

On 03/17/2025, from 11:50am to 1:30pm, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced initial complaint investigation visit to the facility. LPA Haner-Tomasko met with Administrator Carl Meyer and explained the reason for the visit. During the visit, the LPA requested and received facility documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings.

Investigator Jauregui conducted interviews; on 04/09/2025, at approximately 2:05pm, with the resident representative for R1; on 04/15/2025, from approximately 9:50am to 1:58pm, with the facility Administrator Carl Meyer, staff and residents; at approximately 3:37pm, with Person #1; on 04/18/2025, at approximately 8:15am, with a former staff; on 04/22/2025, at approximately 3:19pm with another former staff; on 07/25/2025, at approximately 8:32am, with Person #2 (P2); on 08/05/2025 and 08/14/2025, additional interviews with Administrator Carl Meyer; and on 08/11/2025, at approximately 1:13pm, an additional interview with former staff. In addition, Investigator Jauregui reviewed medical records from Twin Cities Community Hospital (TCCH), the County of San Luis Obispo, and facility file documents related to the investigation.

On 3/17/2025 and 7/23/2025, LPA Haner-Tomasko interviewed additional staff and the administrator.

On the allegation: Due to lack of supervision, resident has fallen multiple times resulting in injuries. LPA reviewed documents including R1’s physician’s report, pre-admission appraisal, service plan, and incident reports. R1’s physician’s report dated 03/12/2024 indicates R1 was diagnosed with rhabdomyolysis, dementia, hyperlipidemia, anxiety, anemia, and history of falling. R1 was considered nonambulatory, had a visual impairment, required continuous bed care, was confused/disoriented at times, required assistance with bathing, dressing, grooming, and toileting. A pre-admission appraisal dated 3/7/2025 indicates the resident uses a wheelchair for mobility. Interviews revealed R1 got around the facility in their wheelchair .