Complaint Investigation Report

R1 was also left in soiled diapers during the day. Staff stated R1 refused to be changed and the R1 stated that is not true. R1 stated they were not changed on a regular basis and R1 also stated R1 said “yes” to staff when staff asked R1 if they needed to be changed but was not changed. No written incontinent care plan was found in R1's file at the facility during a file review. Home health agency staff stated they found R1 in soiled diapers when they visited R1. Staff 2 (S2) also did not seek medical attention when the pressure injury on R1 worsened. S2 stated they were instructed to put cream on the pressure injury and to put a bandage on it if it fell off between the home health care agency checks. S2 stated they contacted the administrator and the responsible party when they noticed the pressure injury smelled bad and did not send R1 to the hospital until being instructed to do so by the responsible party. R1 was sent to the hospital 07/26/2023 and has not returned.

Title 22 regulations and California Health and Safety Code do not require staff to speak English. However, the regulations do require staff to be competent to provide services necessary to meet resident needs. LPA Hiratsuka was unable to communicate with two separate staff members. The first time was on 08/02/2023, and that staff member (S3) called S2 who showed up and LPA was able to communicate with S2. During the visit LPA met S1 and LPA was unable to communicate with S1 either. LPA found both S1 and S3 working by themselves. S2 stated they live a couple of minutes away and the others can call S2 at any time. Home health agency staff stated they were unable to communicate with S1 when they had questions and S1 had to call S2 and S2 arrived to finish the visits. S1 is also the overnight staff member. There is no proof S1 can call for emergency services by themself.

As a result of this investigation, the Department finds the allegations above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87463(a). The licensee was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code 1569.49.

Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. signature on this report acknowledges receipt of the Appeal Rights