Complaint Investigation Report

547208809-3-21-2025-24-AS-SMOA-DFTPXE-20250417114209

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

01/08/2025 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20250108093803

Executive Director/ Administrator Amanda Kelsey

Resident sustained pressure ulcer due to neglect

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit to deliver findings. LPA met with Administrator Amanda Kelsey and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Based on interviews conducted and records reviewed the facility followed the following plan of care for Resident’s (R1) Care. Resident was bedbound and already getting frequent checks and rotation due to incontinence. Despite frequent rotation the resident developed pressure ulcer sometime around 11/2024 at which point Home Health was initiated by doctor’s orders. Home Health provided wound care while facility continued medication administration for wound and continued checks and rotation.

Based on observation and interview of staff, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore these allegations are unsubstantiated.