Complaint Investigation Report

interviewed staff that reported that they did not know about the condition of R1’s feet or that their feet were swollen, but that they did observe R1 to be walking differently than normal, seemingly in pain. Staff reported being aware that R1 needed to wear support socks, but that R1 had been wearing the wrong socks. This oversight was due to the residents' socks getting mixed up in the laundry bin. Per LPA’s interview with staff, all the residents’ dirty laundry would go in one basket and the socks would get mixed up, so R1 would end up wearing the wrong socks, not compression socks. Other staff informed LPA that they didn't know R1 needed to wear special compression socks. Additionally, LPA review of R1’s Individual Program Plan shows TED hoses listed as a current medication. During investigation, LPA reviewed medical provider telehealth notes that indicate on 9/10/24 R1 had swelling of the feet for about 2 weeks, per caregiver report, and provider observed R1’s feet to be very red and purple. Notes show medical provider determined that R1 needed to be seen immediately either at the Emergency Room or later that afternoon with medical care provider due to the observed condition of R1’s feet and ankles. Additionally, LPA reviewed medical provider notes for R2. Notes indicate that caregiver reported that R2 has had a sore throat and Upper Respiratory Infection symptoms for weeks before medical provider visit, notes also show that R2 was determined to have a pain assessment score of 6 by medical provider during visit. Based on LPA’s interview and photographic evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Licensee does not have control of property Complaint alleges that licensee does not have control of property. The Santa Rosa Regional office learned that the property where the facility is located is in foreclosure and has requested that the Licensee show proof of control of property on multiple occasions including but not limited to the Office Meeting conducted 11/8/2024 and the Case Management inspection conducted 12/19/2024 but Licensee has failed to provide proof to date. Based on LPA’s review of documents and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.