Complaint Investigation Report

LPA conducted confidential interviews with Licensee and facility staff (S1, S2 & S3) revealed conflicting information regarding the timeline and services provided to R1. LPA conducted interviews with residents (R2, R3 & R4) confirmed that staff check them regularly during night shift. According to interviews conducted by LPA with S3, R1 and all other residents were checked hourly. Per S3, the night before R1’s hospitalization, R1 was described as not engaged like R1 used to make gestures to respond to questions, but when they performed their last check at 5am, R1 was observed sleeping, breathing without any signs of distress. Investigation revealed that facility morning staff (S1 & S2) found R1 at around 7:30am when they performed their usual rounds to check on residents, R1 was observed with a significant change of condition, which prompted S1 to call the Licensee immediately. According to interviews conducted with the Licensee, the facility staff informed them about the significant change in condition of R1. Although R1 was observed with signs of distress at about 7:30am, LPA obtained Santa Rosa Fire Department records revealed that they were not contacted until they received emergency call on 10/27/25 at 11:08:54am to transport R1 to the hospital. 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), is cited on the attached LIC 9099D. Appeal Rights Given. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued. The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).