complaint·October 1, 2024

During the prior visit dated 7/26/2024 Licensing Program Analyst (LPA) Angelica Rea made another visit to issue the final results of the investigation. LPA met with Joshua Castillo, who assisted with today's visit. Regarding the allegation that: Facility does not have sufficient staff which has resulted in resident leaving the facility unattended. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Interviews conducted were unable to corroborate that resident #1 left the facility unattended. Attempts were made to interview resident #1's family member, however LPA was unable to interview resident #1's family member to obtain additional information. Resident #1 was no longer living at the facility when LPA conducted initial visit and was not interviewed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided. Regarding the allegation that: Resident developed pressure wounds while in care. The investigation was conducted by the department, and consisted of interviews, review of facility documentation, and review of resident #1 medical records. Hospital records show that resident #1 was admitted to the hospital on 12/5/22 due to a fall and did not have any pressure injuries. Resident #1 was re-admitted to the hospital on 1/16/23 and was diagnosed with an unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. Per facility documentation provided, on 1/10/23, the pressure injuries on resident #1 were noted. Resident #1's family member stated that they were permitted and relied upon to perform wound care from 1/11/23-1/15/23 at the facility. The investigation found sufficient evidence to show that resident #1 developed pressure wounds while in care of the facility. Regarding the allegation that: Facility is neglecting resident's care. The investigation was conducted by the department, and consisted of interviews, review of facility documentation, and review of resident #1 medical records. Per hospital records, upon admittance resident #1 had "oral cavity dryness, crusting, and debris" due to "poor oral intake and poor oral care at the facility". Resident #1 was diagnosed with a staphylococcus (staph) infection in his mouth. Additionally, hospital records show that staff neglect of resident #1, resulted in a weight loss of sixteen pounds within approximately six weeks. On 12/5/22, resident #1 was admitted to the hospital weighing 150 lbs. On 1/16/23, resident #1 was admitted to the hospital weighing 134 lbs. Per reports provided by the facility, dated 1/11/23, 1/12/23, 1/14/23, and 1/15/23, it was noted that resident #1 was unable to eat, chew, or swallow his food. Resident #1 was diagnosed with severe malnutrition upon admittance to hospital on 1/16/23. The investigation found sufficient evidence to show that the facility was neglecting resident #1's care. Regarding the allegation that: Facility failed to provide timely medical attention to resident in care. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Upon being admitted to the hospital on 1/16/23, resident #1 was diagnosed with severe sepsis with acute organ dysfunction, pneumonia, hypernatremia, due to dehydration, severe protein calorie malnutrition, in addition to the unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. The investigation found sufficient evidence to show that the facility failed to provide timely medical attention to resident #1. Based on interviews which were conducted with staff and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 9099D. Immediate Civil Penalty will be issued in the amount of $500.00. The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e) or (f). Exit interview conducted and copy of report and appeal rights were provided on 7/26/2024.