complaint·January 12, 2026

Continued LIC9099-C page 2. Progress Notes (dated 04/22/2025-05/12/2025, Ideal Home Health Records (dated 05/06/2025), California Wound Healing Medical Group (dated 05/01/2025), Outside Agency Documentation (dated 02/09/2024-07/23/2024), Special Incident Reports (dated 05/08/2025), and Emails (dated 08/27/2024, 11/06/2024, 04/03/2025, and 05/04/2025). On 05/14/2025, at 11:30 A.M., the department toured the facility buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit. On 05/14/2025, between 9:30 a.m. and 12:30 p.m., and on 05/28/2025, between 9:30 a.m. and 3:30 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#3 (S1–S3). On 05/14/2025, at 12:30 p.m., LPA Bunker conducted interviews with resident #1 (R1) and witness #1 (W1-W2). The investigation revealed the following. Allegation: Staff neglect resulted in the resident developing a pressure injury. It was alleged that staff neglect resulted in the resident developing a pressure injury. Staff members #1–3 (S1–S3) interviewed stated that R1 never disclosed a pressure injury. 3 out of 3 staff members stated they did not know about any pressure injury to R1's body. The facility was not required to bathe R1; however, the facility assisted, and R1 was bathed by his home health agency. R1 was ambulatory until R1 sustained a fall while on a visit with his family at church. R1 required rehabilitation, which R1 received outside the facility. Records indicate R1 developed a pressure injury while at the rehabilitation center. Studio Royale sent a representative to the rehabilitation center for evaluation before R1 returned to Studio Royale. The rehabilitation center made note that R1 was able to return to Studio Royale; however, upon R1's return to Studio Royale, it was noted that the pressure injury had not been resolved. The facility made several attempts to provide many options for R1 and communicated these options to his power of attorney (POA) with no results. Upon a scheduled doctor’s appointment, R1 was subsequently admitted to the hospital for the pressure injury. The facility staff were interviewed and denied any neglect or lack of supervision. The Department found no evidence that R1's pressure injury manifested while at the facility. See continued LIC9099-C page 2. Continued LIC9099-C page 3. Allegation: Staff retained the resident requiring a higher level of care. It was alleged that staff retained a resident who required a higher level of care. Staff members #1–#3 (S1–S3) were interviewed and stated that R1 was not retained due to needing a higher level of care. 3 out of 3 staff stated R1 was gone from the facility from August 21, 2024, to May 03, 2025. 3 out of 3 staff members stated R1 was ambulatory. When R1 returned. R1 was non-ambulatory and used a power wheelchair. R1’s Case Manager reported that R1 had a Stage 2 wound. On May 3, 2025, when R1 returned from the hospital, the Home Health nurse assessed the wound as Stage 4. R1’s care needs increased significantly, and R1 required a higher level of care. That same day, R1 was sent back to the hospital and later returned to the facility. S1 and S2 stated they attempted to arrange a higher level of care, but R1 refused both transfer and hospice services. S1–S2 stated they would never discharge R1 without securing appropriate placement. S1–S3 also stated that they informed R1’s Power of Attorney (POA) that R1 needed a higher level of care. On May 14, 2025, the Department interviewed R1. R1 did not mention requiring a higher level of care and repeatedly questioned the purpose of the interview before walking away. On May 14, 2025, at 11:50 a.m., the Department interviewed Witnesses #1 and #2 (W1–W2) together via telephone. W1–W2 stated that staff retained R1 despite R1’s increased care needs. However, they confirmed that on May 8, 2025, a meeting occurred with Studio Royale, R1’s family, R1’s attorney, and the Ombudsman. During that meeting, the family requested additional time to find a suitable placement for R1, and the facility agreed to take no further action until after a follow-up discussion scheduled for May 9, 2025. 2 out of 3 staff members stated that staff communicated R1's care needs with R1’s POA. 3 out of 3 staff members denied the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to the Executive Director Bill Boles. No deficiencies were cited. An exit interview was conducted.