complaint·November 21, 2025

It is being alleged that changes in conditions are going unnoticed which lead to hospitalizations. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of 10 residents denied the allegation above and reported seeing a Dr. when needed. 2 of 10 residents confirmed the allegation and reported they have not been seen by a Dr. when they do not feel good. On 10/20/25 from 1pm-2:30pm LPA conduct interviews with S1-S7. 7 of 7 staff interviewed denied the allegation above and reported that med techs or LVN will assess a resident for change in condition, and resident will be sent out as needed. Additionally, during interview S1 reported that when a change in condition is observed the standard would be to call 911. On 10/20/25 LPA conducted a file review of R11-13 files. During file review LPA did not observe a re-assessment available for review when R11 returned from the hospital. LP A also observed that there was no care plan for the catheter R11 returned to the facility with, nor was there any documentation indicating that staff have been trained in catheter care. Based on LPAs observations and interviews conducted, record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.