complaint·July 31, 2025

The investigation revealed the following: Regarding the Allegation: Facility staff did not meet residents’ incontinent care needs. It is alleged that residents’ Urinary Tract Infection (UTI) was a result of staff not meeting residents’ incontinent care needs. Records reviewed indicate the following: Physician report dated 01/10/2024 indicates that R1 is non-ambulatory, is not able to care for own toileting needs and requires continuous bed care. The service plan dated 09/06/2024 indicates that R1 needs full assistance with toileting. Incident reports indicate that R1 was taken to the hospital on 04/02/2025 and evaluated with a urinary tract infection (UTI). Saint John records indicate that R1 was diagnosed with a UTI on 04/02/2025. Interviews indicate the following: 5 out of 5 staff denied the allegation. 7 out of 9 residents denied the allegation. 2 out of 9 residents agree with the allegation. R1 indicated that staff do not change R1 diaper prior to 12 noon most of the time. R2 indicates that R2 witnessed that staff does not change R1 diaper prior to 12 noon. W1 indicates that on 03/29/2025 W1 witnessed that R1 diaper was not changed and was full. Based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the allegation “Facility staff did not meet residents’ incontinent care needs.” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D. Per Title 22 Regulation 87761(c)(1) Penalties a civil penalty is being cited please see LIC421IM. An exit interview was conducted, and a copy of the Complaint Investigation Report, Civil Penalty Assessment and Appeal Rights were provided to the Administrator Nathaniel Venson (S1).