Complaint Investigation Report
R1’s Appraisal/Needs and Services Plan states “[R1] wears depends, sometimes knows when to use the toilet, [He/She] needs assistance with [his/her] ADLs (Activities of Daily Living) in all times.”
On 08/27/2025, the department obtained copies of the facility weekly staff schedules from 07/28/2025 to 08/31/2025. The staff schedules indicate there are at least four staff scheduled each day from 6:00 AM to 6:00 PM, at least three staff scheduled from 6:00 PM to 10:00 PM and one staff scheduled from 11:00 PM to 5:00 AM.
Allegation: Staff left resident soiled for an extended period of time
During visit on 10/01/2025, LPA Marrufo attempted to interview R1, but R1 refused to be interviewed.
On 10/01/2025, LPA Marrufo interviewed witness W1. W1 stated during interview that W1 visits R1 at least once per week. W1 stated to visit R1 for at least three hours at a time. W1 stated to have not observed R1 left soiled for an extended period of time. W1 stated W1 states R1 is sometimes soiled when W1 arrives at the facility to visit R1. W1 stated R1 sometimes resists staff assisting R1 with changing clothes. W1 stated R1 sometimes puts on his/her diapers incorrectly so that the diaper padding is on R1’s stomach. W1 stated R1 does have rashes which W1 believes is from urine contact.
During visit on 10/01/2025, LPA Marrufo interviewed staff S1-S6. S1-S3 stated to have not observed R1 left soiled for an extended period of time. S1-S3 stated that staff change R1 every one and a half to two hours. S4 stated to not have observed R1 soiled for an extended period of time. S5 stated R1 prefers to go to the bathroom by himself/herself. S5 stated that R1 has been offered to use a portable chair in the bathroom, but R1 has denied the offer. S5 stated that staff have put padding on R1’s wheelchair and staff clean R1’s wheelchair if it is soaked with urine. S6 stated to have not observed R1 left soiled for an extended period of time. S6 stated staff is always helping R1 go to the bathroom and S6 reminds staff to check if R1 is soaked every one and a half to two hours.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction