Complaint Investigation Report

415601009-5-12-2025-14-AS-KHOS-DGTN55-20250519100900

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN BRUNO RO , 851 TRAEGER AVE., SUITE 360

This is an official report of an unannounced visit/investigation of a complaint received in our office on

02/26/2025 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 14-AS-20250226164710

Staff neglected to provide medical attention resulting into a stage 2 pressure injury

On 5/12/2025 LPA Grace Donato made an unannounced complaint investigation visit to deliver findings. LPA met with Care Staff Jack Liang and explained the purpose of the visit.

Regarding the allegation, staff neglected to provide medical attention resulting into a stage 2 pressure injury, according to the reporting party, Resident 1 (R1) was observed to have a stage 2 pressure ulcer on his/her left heel that was still developing.

LPA Charitra obtained the latest reappraisal of the resident dated 1/1/2025. There are no observations documenting a wound or stage 1 or 2 pressure injury. LPA Donato requested documentation of home health agreement from facility as proof that the stage 2 pressure ulcer was being addressed. After phone calls and emails, the facility was not able to present any written agreement.

Based on records review, the allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed and copy is provided with appeal rights.