Complaint·February 12, 2026

Investigation revealed the following: Allegation: “Staff left residents in soiled diapers for an extended period of time”, it is being alleged that Staff 1 (S1) left R1 in soiled diaper for an extended period of time. Interview conducted with W1 revealed the following: W1 agrees with the allegation. W1 goes on to explain that on 01/30/2026, R1 texted W1 that they were left in soiled diapers all night, moreover, W1 added that R1 informed them that they do not receive incontinence care at night when S1 is on shift. Interview conducted with R1 revealed the following: R1 agreed with the allegation. R1 indicated that they were left in soiled diapers all night and changed in the morning, R1 added that they pushed the call button several times, but no one came. R1 stated that S1 informed them that they do not assist with incontinence care needs between the hours of 7 pm to 7 am. R1 indicated that other staff assist with incontinence care needs at night. Interviews conducted with W1, R1 and S4 revealed the following: W1, R1, and S4 all indicated that they have discussed the issue of R1 being left in soiled diapers for an extended period of time; they indicated that S4 has addressed the issue and resolved the problem. Records reviewed of text messages between R1 and W1 revealed the following: On 01/30/2026 at 8:27 AM, R1 texted W1 stating that they had a bowel movement at 12 am and got a diaper change at 7:30 am that morning; R1 indicated that S1 was working night shift. R1’s records reviewed revealed the following: Admission Agreement dated 10/02/2025, includes “Basic services at a minimum include: …toileting.” Medical Assessment for Residential Care Facilities for the Elderly dated 10/01/2025 states that R1 is non-ambulatory, has bowel incontinence, and needs assistance with toileting needs. Preplacement Appraisal Information dated 10/02/2025 indicates that R1 needs help with toileting. Substantiated: Based on interviews and 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 being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the House Manager, Irma Inducil.