complaint·November 19, 2025

Allegation: Staff neglect resulted in resident hospitalization Investigation Finding: Substantiated During investigation, the Department reviewed resident’s (R1) medical records which showed R1 was admitted to the hospital twice (08/02/24 and 08/06/24) in one week due to heat exposure. On 08/02/24 at approximately 1800 hours, R1 was found outside the facility lying on concrete for an unknown period of time. It was noted that it was nearly 100 degrees Fahrenheit that day. 911 was called and emergency Medical Services (EMS) recorded R1’s body temperature at 107degrees Fahrenheit. R1 was transported to the hospital where he was admitted and diagnosed with heat exposure. On 08/06/24 at approximately 1630 hours, R1 was found by staff outside the facility on his wheelchair unresponsive. 911 was called and staff administered Cardiopulmonary resuscitation (CPR) until EMS personnel arrived. R1 had a weak pulse with his body hot to the touch. It was noted that it was also very hot outside that day with temperatures close to 100 degrees Fahrenheit. 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 neglect resulted in resident hospitalization was found to be substantiated. On 7/30/25 S1 was interviewed and reported that on 8/2/24 S1 noticed from the medication room monitor that R1 was lying down outside of the patio area and believed that he had been on the ground for 45 minutes. S1 further stated that R1 was hot to the touch and that S1 had called for assistance but none responded to the calls and that other staff remained “sitting around.” S1 also reported that on 8/6/25 that R1 was found by non-caregiver staff outside in R1’s wheelchair. S1 came out to check R1 and found R1 to be unresponsive and not breathing. S1 stated that care staff neglected R1 because he had previously been hospitalized for being left outside . Immediate civil penalty of $500 assessed during visit. Additional civil penalty determination is pending relating to this complaint. Deficiency is 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.