complaint·June 4, 2025

Allegation: Staff allowed a resident to be soiled while in care Investigation Finding: Substantiated During investigation, LPA interviewed reporting party (RP), home health aide (HHA) staff (ADM, S1, S2). Staff (S1, S2, stated they did not find any issue with any resident on 05/22/25 while on duty from 7AM to 7PM. LPA confirmed with HHA that when she arrived on 05/22/25 at 7:30AM to provide care to R1, she found resident lying in bed horizontally with the head of the bed elevated to a sitting position and the foot of the bed also elevated to the highest point, creating a “V” position. HHA stated R1 had a soiled brief and bowel movement, with feces smeared on the bed, bed rails and on R1’s hair. HHA also stated R1 had torn the soiled bed linens to reposition herself or get out of bed. HHA stated she gave R1 a bath and changed her clothes that day. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff allowed a resident to be soiled while in care was found to be substantiated. Allegation: Staff did not meet the needs of a resident while in care Investigation Finding: Substantiated During investigation, LPA interviewed reporting party (RP), home health aide (HHA) staff (S1, S2). HHA confirmed with LPA that when she arrived on 05/22/25 at 7:30AM to provide personal care to R1, she found R1 had a soiled brief and bowel movement, with feces smeared on the bed, bed rails and on her hair. HHA also stated R1 had torn the soiled bed linens to reposition herself or get out of bed. LPA interviewed staff (S1, S2) who stated that they were not aware that R1 had soiled herself in bed on 05/22/25. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not meet the needs of a resident in care was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.