complaint·January 19, 2023

The investigation for this allegation was conducted by Investigator Peter Zertuche. During the course of this investigation, Investigator Zertuche, reviewed hospice records in which indicate the victim (R-2) was admitted to this facility on 10/13/2020 “without impairments but after a few days, two pressure injuries began to form. The facility was directed to reposition every two hours, but it was noted on hospice records that the victim (R-2) was in the same position during every nurse visit. Approximately one week after being admitted to the facility, the victim’s (R-2) pressure injuries worsened and on October 28, 2020, the injury was unstageable. Hospice records also noted that the facility did not reposition as necessary and poor care was provided. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to Resident developed pressure injuries while in care. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(B)(i) and may be assessed at a later date. Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421IM (Civil Penalty Assessment), and Appeal Rights were provided to Emma Topadzhikyan Allegation: Resident's hygiene needs are not being met. During today’s visit, LPA interviewed Resident #3 (R-3), Resident #4 (R-4) and Resident #5 (R-5). LPA was unable to interview Resident #6 (R-6) as R-6 was asleep at the this of this visit. LPA was unable to interview Resident #1 (R-1) and Resident #2 (R-2) as they no longer reside at this facility. LPA also interviewed Staff #1 through Staff #3 (S-1 through S-3). Resident interviews revealed that staff provide assistance with residents’ hygiene needs. Interviewed residents indicated they do not have any concerns and that their hygiene needs (including dental) are being met by staff. Staff interviews revealed that staff assist resident with their hygiene needs including oral hygiene on a daily basis. Interviewed staff indicated that staff do not keep a log to reflect that residents were assisted with oral hygiene. Interviewed staff indicated they have not received any complaints/concerns in regards to residents hygiene needs not being met. During this visit, LPA also observed staff assisting residents with their hygiene needs and also observed residents to have hygiene supplies. Resident and staff interviews do not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore this allegation is unsubstantiated. Exit interview conducted and appeal rights and a copy of this report was provided to Emma Topadzhikyan.