complaint·December 2, 2025

(Continued from 9099) Water temperature was tested in each residents room and tested between 108.0 -109.2 degrees F., which is within the required 105-120 degrees F. LPA reviewed and requested copies of resident #1(R1)'s file. LPA interviewed Administrator. No health and safety hazards were observed during visit. LPA reviewed and obtained resident’s hospital records, home health records, and other pertinent medical information. LPA also reviewed the department’s investigation reports. LPA interviewed five (5) staff and five (5) residents. Allegation: Staff neglect resulted in a resident sustaining multiple pressure injuries . It is alleged that facility staff neglected resident which caused resident to develop pressure injuries. The investigation revealed: LPA interviewed five (5) staff, and three (3) of five (5) staff denied the allegation, stating they were not aware of the allegation. Two (2) staff stated they reported the wound(s) to their supervisor who no longer works at facility. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. The department investigated this allegation and presented the following. The resident moved into the facility on 9/11/2024 with no pressure injuries. He was identified as needing full assistance with bathing and dressing in the resident assessment dated 09/11/2024. Caregivers did not observe or address the wounds during bathing and dressing tasks. On 11/16/2024 the resident was discovered with an open wound pressure injury on resident’s sacral area that was described as stage 3 wound by an Agency Med Tech who saw the resident’s wound the day of discovery. The resident was admitted to the hospital on 11/19/2024 and was diagnosed with an unstageable pressure injury on his sacral area. In addition to the sacral pressure injury, deep tissue pressure injuries (DTIs) were discovered on the victim’s right hip, as well as on his left and right heels, and feet. Facility caregivers failed to provide an appropriate level of care and supervision resulting in pressure injuries. There is enough evidence to prove that facility staff neglected resident causing resident to sustain pressure injuries. Allegation: Lack of supervision lead to multiple falls resulting in injuries. It is alleged that resident had multiple falls that led to injuries. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. Resident had been residing in the Baldwin Gardens Skilled Nursing facility from 12/24/2023 until 9/11/2024. The resident was sent to Arcadia USC Hospital on 7/15/2024 and a CT of the victim’s head was done. The CT scan revealed no injuries, and no subdural hematomas were found on the CT scan. After returning to the SNF the resident was placed onto one-on one supervision for the remainder of his time there and resident had no further falls. Records revealed the resident had two falls while residing at the facility, the first fall occurred on 9/14/2024. (CONTINUED) (Continued from (9099C) The date for the second fall is not clear but possibly around 10/20/2024. Resident was not taken to hospital during those falls despite residing in the memory care section. On 11/19/2024 Resident was diagnosed with hematoma; however, there is no evidence that the Injury/hematoma developed due to fall(s) on 09/14/2024 and 10/20/2024. A review of the records indicated that during a home health nursing visit on 10/30/2024 nurse learned that the victim had a fall on 10/23/2024 while walking to the bathroom. Home Health notes for 11/8/2024 indicated the victim had a laceration on his shin due to the fall. On 11/15/2024 the victim was seen by a home health nurse and the wound was healed There is enough evidence to support this allegation. Allegation: Staff did not address a resident's change in medical condition. It is alleged that resident had a change of condition and staff did not address it. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. It is documented by hospital admission records that resident arrived at emergency room on 11/19/2025 with a sacral wound that was diagnosed as unstageable and resident had developed eight (8) deep tissue pressure injuries (right elbow, right hip, right lateral ankle, right lateral foot, left medial foot, left lateral ankle, and left heel. Resident had a change of condition days before been sent to hospital and staff did not address the change of condition. There is enough evidence to substantiate this allegation. Staff did not seek timely medical attention for a resident. It is alleged that staff did not provide timely medical attention to resident after resident suffered two falls. LPA interviewed five (5) staff, and five (5) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate with the allegation. Facility records revealed the resident had two falls while residing at the facility, the first fall occurred on 9/14/2024. The date for the second fall is not clear but possibly around 10/20/2024. and resident was not taken to the hospital for medical assessment despite residing in the memory care section of the facility. No other falls were listed in the obtained notes. The facility did not obtain timely wound care/medical attention to address the developing pressure injuries resulting in the multiple pressure injuries identified in the first allegation. There is sufficient evidence to substantiate this allegation. Allegation: Staff did not ensure a resident consumed an appropriate amount of liquid while in care. It is alleged that staff did not ensure resident was provided with an appropriate amount of liquids that lead to resident being diagnosed with dehydration when admitted to hospital on 11/19/2024. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. Several staff stated resident refused food and liquids. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. Resident was admitted to hospital on 11/19/2024 and hospital records show that resident was dehydrated on arrival. Facility records show that resident suffered from diarrhea and staff did not ensure resident consumed enough liquids. There is sufficient evidence to substantiate this allegation. (CONTINUED) (Continued from 9099C) Based on the department's interviews which were conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Deficiencies noted on LIC 9099D. Exit interview was conducted with Maria Quizon, Administrator and Michelle Castillo, Business Office Manger, and a copy of this report, LIC 9099D, and appeal rights were provided.