Complaint·August 25, 2025

Continued - Unsubstantiated This Department investigated the allegation: Resident sustained a bed sore while in care. R1 was hospitalized on 12/12 and again on 12/13/25 – on both dates, records indicate assessments conducted with no skin issues. An RN took a photo on 12/14/24 that appears to be a wound or sore. On 1215/24 a wound specialist described R1’s wound as a “full thickness wound”. The cause is unknown, and the specialist did not determine a stage or specific diagnosis provided. It is unable to be determined when the skin issue originated or the cause of the injury. This Department investigated the allegation: R1 moved into the facility with a known diagnosis of Diabetes per Physician Report dated 10/11/22. The facility did not have Physician Orders to monitor or test R1’s blood sugar. Though the facility did not have orders to test blood sugar, there also were no interventions in place per the current Service Plan dated 5/31/23 to monitor or identify possible changes in condition to Diabetic related conditions or emergencies. This Department investigated the allegation: Staff do not safeguard a resident's personal belongings. Interviews with Care Staff and Memory Care Director (MCD) confirmed the missing belongings. Interviews confirm searches for these items were conducted, but they were not found. Employee and Family members state that a log of personal belongings was not maintained. Record review reveals that upon admission, LIC621 Client/Resident Personal Property and Valuables was not completed. A blank copy with a line through it was located in R1’s file. Based on interview and record review the above allegations are UNSUBSTANTIATED . Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided. Continuation of substantiated report The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An Immediate Civil Penalty is being assessed for $500 on the attached on the attached LIC421IM. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were