complaint·December 5, 2025

The investigation consisted of the following: LPA Ramirez requested and obtained a copy of Resident/Client Roster, copies of Resident#6 (R6): Admission Agreement, Medical Assessment, Identification and Emergency Information, Appraisal/Needs and services plan, Medication Administration Record (MAR) for March – May 2025, Vital logs Jan-April 2025, Repositioning/Diaper Change Log for March, April and May 2025, R6's Hospital Medical Records, R6's Home Health Medical Records, R6's Medical Records copy of Staff Roster, Staff#1 - 5 interviews (S1 – S5) conducted by LPA Ramirez, Resident#2, 5 interviews (R2, R5) conducted by LPA Ramirez, Interview with resident#4’s (R4) family conducted by LPA Ramirez, Interviews conducted by Community Care Licensing-Investigations Branch, Investigations Branch-Investigation Report completed 10/7/2025, and physical plant tour. The investigation revealed the following: regarding the allegation “Staff did not prevent resident in care from sustaining multiple pressure injuries while in care.” Interviews conducted by Community Care Licensing-Investigations Branch corroborated this allegation. Records reviewed by Community Care Licensing-Investigations Branch revealed that R6 was discharged from a local hospital on 03/19/2025 with a Stage I coccyx pressure injury and R6 was admitted to the facility on 03/19/2025. Records reviewed by Community Care Licensing-Investigations Branch revealed that in April of 2025, R6's Home Health and R6's physician noted several pressure injuries had developed on R6’s feet, ranging from Stage II to unstageable, and R6’s coccyx pressure injury had progressed to Stage II. On 04/29/2025, R6 was taken to a local hospital due to worsening pressure injuries. During the examination of R6, attending physician noted the pressure injuries were likely caused by the care at the facility. Interview conducted by Community Care Licensing-Investigations Branch with R6's Home Health nurse revealed that R6’s pressure injuries continued to worsen and develop new pressure injuries due to the staff’s inability to follow repeated education and instructions on pressure injury care and that with frequent repositioning, R6’s pressure injuries “could have been avoided.” R6's Home Health nurse revealed that on one occasion, staff were observed applying cream to R6’s coccyx injury but staff did not apply the dressing to keep the area dry, as instructed. Interviews conducted by Community Care Licensing-Investigations Branch with facility staff revealed that staff were not repositioning R6 often as needed. The information gathered during this investigation noted that R6’s pressure injuries worsened due to staff not following instructions pertaining to proper care and lack of timely repositioning. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . One (1) deficiency was issued. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). Exit interview was conducted. A copy of this report, 9099-D, and appeals rights were provided. The investigation revealed the following: regarding the allegations “Staff handled resident in a rough manner resulting in an injury.” Interviews conducted by LPA Ramirez with five (5) staff did not corroborate this allegation. Staff interviews revealed R6 would become combative and aggressive with staff when staff tried to assist R6 with ADL’s (activities of daily living). Staff revealed R6 would get agitated and combative when staff attempted to put shoes on R6, as a result staff revealed they would allow R6 “space” and contacted R6’s family to inform them of R6’s refusal to wear shoes for walking and combativeness. Six (6) out of the six (6) staff interviewed denied handling R6 in a rough manner that resulted in an injury. LPA Ramirez reviewed R6’s facility file and did not observe facility incident reports that indicated R6 sustained an injury due to staff handling R6 in a rough manner. LPA Ramirez interviewed R4’s family and they revealed that they are in the facility most days for several hours and have never witnessed staff being aggressive or rough with residents. Two (2) out of the two (2) residents interviewed denied this allegation. Interview with R2 revealed that staff were “caring” with all the residents. Three (3) out of the five (5) residents in care were unable to be interviewed due to cognitive impairments. Due to cognitive impairments, R6 was unable to be interviewed. 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 UNSUBSTANTIATED. “Staff shared resident’s medication between other residents in care.” Interviews conducted by LPA Ramirez with five (5) staff did not corroborate this allegation. Staff interviews revealed no medication is shared between residents because each resident has a different prescription and strength. Two (2) out of the two (2) residents interviewed denied this allegation. Interview with R4’s family revealed that R4 has always received their medication in a timely manner and medication was administered according to R4’s physician’s order. Three (3) out of the five (5) residents in care were unable to be interviewed due to cognitive impairments. Due to cognitive impairments, R6 was unable to be interviewed. During the record review, LPA Ramirez examined the medication administration record (MAR) for five (5) out of the five residents in care and did not observe any discrepancies. During facility tour, LPA Ramirez conducted an observation of staff administering medication to residents in care and noted no irregularities or concerns. 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 UNSUBSTANTIATED. SEE 9099-C for continued report “Staff did not implement proper infection control practices.” Interviews conducted by LPA Ramirez with five (5) staff did not corroborate this allegation. Staff interviews revealed that staff clean and disinfect high trafficked areas at least every 2 hours and staff always wear gloves while providing first aid, toileting and when bathing residents. During record review of personnel records, LPA Ramirez observed annual staff training on infection control practices. LPA Ramirez examined the facility approved Infection Control Plan. During facility tour, LPA Ramirez conducted an observation of staff administering medication to residents in care and noted staff were wearing gloves and a face mask. LPA Ramirez observed the facility to be free from odors and did not observe potential hazards. 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 UNSUBSTANTIATED. “Staff covered resident’s face with a beanie.” Interviews conducted by LPA Ramirez with five (5) staff did not corroborate this allegation. Two (2) out of the two (2) residents interviewed denied this allegation. Interview with R4’s family revealed that they have only observed staff to be professional with their loved one and other residents in the facility. Three (3) out of the five (5) residents in care were unable to be interviewed due to cognitive impairments. Due to cognitive impairments, R6 was unable to be interviewed. During record review of personnel records, LPA Ramirez did not observe documentation of staff being reprimanded treatment of residents in care. 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 UNSUBSTANTIATED. No deficiencies were cited for these allegations. Exit interview was conducted. A copy of this report was provided.