complaint·March 16, 2026

Regarding the allegation: Staff did not prevent a resident from developing a pressure injury while in care. It is being alleged that Resident #1 (R1) had a pressure injury in their sacral area. LPA obtained medical records from Northridge Hospital, and it was determined that R1 had a Stage 1 pressure injury on their sacrum. Staff #1 (S1) confirmed that R1 was under “Prosper Home Health,” which provided services to R1 such as taking blood work, issuing medication, and assisting R1 with showers. During LPA’s record review of the facility and medical records from Northridge Hospital, it was determined that R1 had Stage 4 choriocarcinoma cancer with metastasis. During LPA’s interview with the nurse who was providing care to R1 through Home Health, the nurse stated, “R1 was not being provided wound care because R1 did not have a wound.” Therefore, based on the record review and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not feed a resident in care. It is being alleged that Resident #1 (R1) was not being fed due to them not being able to walk to the dining area. LPA interviewed two (2) residents who confirmed they receive all their meals regardless of whether they eat in the dining area or not. One (1) resident confirmed that if they do not feel well, the caregiver brings the meal to their room. During LPA’s interview with R1’s sister, they stated that when they visited R1, R1 had leftover food in their room. During LPA’s staff interviews, both staff confirmed that R1 became very sick and would not eat all the time. Both stated, “Even if we would take the food to R1’s room, it would sometimes stay untouched.” During LPA’s interview with Staff #1 (S1), S1 confirmed that R1 had cancer and was declining very quickly. S1 also stated that R1’s medical assessment had to be updated because when R1 first arrived at the facility, R1 did not have a special diet and did not require incontinence care; however, due to the health decline, R1 was later placed on a special diet and required incontinence assistance. During LPA’s record review of the facility and medical records from Northridge Hospital, it was determined that R1 had Stage 4 choriocarcinoma cancer. Therefore, based on the record review and interviews conducted, the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff did not provide sufficient drinking water to a resident in care. It is being alleged that Resident #1 (R1) seemed extremely thirsty at times. LPA interviewed two (2) residents who confirmed they receive all their meals and do not have any issues obtaining drinks. One (1) resident stated they like to drink sodas, and the other resident stated they can drink whatever beverages the facility has available. During LPA’s physical tour of the garage, cases of bottled water were observed. During LPA’s interview with R1’s sister, they stated that when they visited R1, R1 had drank multiple water bottles. During LPA’s staff interviews, two (2) staff confirmed that there is plenty of food and different drinks available for the residents, including water. Both staff also confirmed that R1 was diabetic and at times drank a lot of water and had multiple water bottles in their room. During LPA’s record review, it was determined that R1 was diabetic. Therefore, based on the record review and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not allow a resident to receive telephone calls. It is being alleged that Resident #1 (R1) had no phone privileges. During LPA’s visit on 01/30/26, LPA observed the facility phone ring, and it was for a resident who did not have their own cell phone; the resident was able to use the facility phone. LPA interviewed two (2) other residents who have their own cell phones and do not need to use the facility phone. During LPA’s interview with Staff #1 (S1), who stated that R1 did not have their own cell phone but did receive phone calls from their sister at the facility. S1 also stated that at times R1 was too sick to speak with their sister and would decline the phone calls. Staff #2 (S2) stated that R1 was able to walk when they first came to the facility, but when their health declined, R1 preferred to stay in their room and not speak to anyone. Therefore, based on the record review and interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) issued, and a copy of this report was given to the Administrator.