complaint·March 5, 2026

The investigation determined the following: Regarding the allegation: Resident sustained Stage 3 Pressure injuries while in care. It was alleged that Resident 1 (R1) sustained pressure injuries due to the neglect and the lack of care from the facility staff. To investigate the allegation, IB Garcia conducted interviews with three staff members (S1-S3) between the dates of 6/13/2025 to 11/18/2025. IB Garcia’s interview with S1 revealed that staff are required to conduct sponge baths to all residents every day. S1 confirmed that R1 did not have home health or a wound care plan in place. Further interview with S1 revealed that, “…the incident was a lesson for them”. IB Garcia’s interview with S2 revealed that R1’s pressure wounds would emit unpleasant odors along with discoloration, yet they did not seek out any medical assistance for R1’s wound. Additionally, S2 was also unable to provide any body-check logs pertaining to R1. IB Garcia’s interview with S3 revealed that they did not conduct body checks on R1, yet they noticed redness around R1’s pelvic area but did not seek out medical treatment. On 05/09/2025, Special Investigator Assistant (SIA) Amina Luckett subpoenaed R1’s medical records from Palmdale Regional Medical Center. IB Garcia’s record review revealed R1 was admitted on 4/18/2025 where they were examined and the following was observed: a diabetic ulcer to their left heel, a pressure wound to the right lateral ankle measuring, an unstageable pressure wound to the sacrum measuring and moisture-associated skin damage (MASD) to peri wounds. Furthermore, based on IB’s investigation there is enough evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure resident's diapering needs were properly met. It was alleged that staff did not ensure R1’s diapering needs were properly met. To investigate the allegation, IB Garcia conducted interviews with three staff members (S1-S3) between the dates of 6/13/2025 to 11/18/2025. IB Garcia’s interview with S2 revealed that they failed to check R1 every two hours during their nightshift to see if they required a change in diapering. IB Garcia’s interview with S3 revealed that they would change R1’s diaper when it was “almost leaking” due to R1’s refusal to be changed. Interviews with both S2 and S3 revealed that R1 was capable of requesting when their diaper needed to be changed, however IB Garcia notated that due to R1’s cognitive diagnosis they could not be interviewed. LPA Segovia’s record review on 12/09/2025 of R1’s Physician Report confirmed that R1 had been documented to have cognitive impairments. (Continue to LIC 9099-C) Based on record review and IB’s investigation there is enough evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Citation issued, please refer to LIC 9099-D. Civil penalty assessed. An immediate civil penalty of $500 was assessed today for a violation resulting in an immediate hazard to the health and safety of R1. The House Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). No other immediate health and safety hazards observed during the time of the visit. Exit interview was conducted, appeal rights were given, and a copy of the report was provided to the House Manager, Richard Garcia Regarding the allegation: Staff did not safeguard resident's personal items. It was alleged that facility staff failed to care for R1’s personal belongings. To investigate the allegation, LPA Segovia attempted interviews with seven (7) residents and four (4) staff members. Per the Reporting Party (RP), three (3) clothing items belonging to R1 were damaged and stained with bleach. LPA’s interview with three (3) residents revealed that staff have not damaged their personal property such as clothing. LPA attempted to interview R1, but they no longer reside at the facility. LPA attempted to interview R5 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA attempted to interview R6 and R7, but they were asleep during LPA’s visit. LPA’s interview with S1 revealed that R1’s damaged clothing was never brought to their attention, nor had they witnessed R1’s clothing to be damaged. LPA’s interview with both S1 and S4 confirmed residents’ clothing are washed everyday with no issues. LPA attempted to interview S2, but they no longer work at the facility. LPA attempted to interview S3, but they were not present during LPA’s visit. During LPA’s physical plant tour, LPA observed residents to be dressed appropriately and well groomed. LPA did not observe any damage to their clothing. LPA observed the laundry appliances to be working and in proper condition. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other immediate health and safety hazards observed during the time of the visit. Exit interview was conducted, and a copy of the report was provided to the House Manager.