Complaint Investigation Report

On 5/22/26 LPA Chiarelli received an incident report, the incident reported an incident that happened with (resident one) R1 on 5/21/26. The incident was that a caregiver (C1) at the facility provided wound care to a resident when a blister was popped which created a larger wound by a caregiver (C1) at the facility. R1 is currently receiving wound care from hospice. During the investigation two hospice nurses were interviewed.

While reviewing the incident report it gives a statement from the staff member (C1) who was involved in the incident their statement stated: “She said she was aware that she was not supposed to pop it but that she thought she was helping him and that she would never do it again and she was so sorry.” When LPA Chiarelli inferred about the statement to C1s supervisor they stated that statement was what C1 told them.

Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.