complaint·October 30, 2025

Continued from LIC9099: Interviews with 3 staff (S1, S2, & S3) who care for residents on 3rd floor revealed none of them had given R1 a shower/bath, for the approximate 3 weeks R1 was at facility. Interview with R4 revealed protocol is, when a resident is admitted to the facility, staff put them on a shower schedule 2 times a week (unless otherwise requested) and then sign log each time a shower is given or indicate a refusal or indicate refusal in daily notes, which was not completed in this case. There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "facility staff are not meeting residents’ care needs", therefore, the allegation is Substantiated . Responsible party not notified of resident fall - Reporting party alleges facility did not notify/call responsible party of residents fall until in person, hours later when resident was at the hospital. Incident report received indicates facility was aware at approximately 7:45 am but POA/Responsible Party told in person at 10am when arrived at facility for regular visit. Interview with S5 informed the processes of inputting new resident information: obtain residents information from POA then S5 types it up on Emergency contact forms (attachment #5) & Resident & responsible party information form (attachment #6) etc. then provide to RCD their portions who then implements into their computer system. Documents obtained revealed the Identification document handwritten from the POA is the same on the emergency contact form but on the responsible party information form the last number of the phone number was turned from 9 to 3. S4 typed in the number from the responsible party information which was wrong as indicated on the facility online resident contact number for their POA. 9/11/25 at 10am Progress Notes & Incident report submitted to CCL on 9/16/25 of 9/11/25 incident for R1 indicates Med Tech called POA 3 times starting at 7:45am not getting any answer and finally left a message. Progress notes also indicated S4 notified POA at 10am when they came into the facility to visit. Interview with S1 informed when there is a fall or emergency and they need to contact the family they go to the online information. Investigation revealed S1 called R1’s POA when incident occurred on 9/11/2025 at approximately 7:45am, although they were dialing the wrong number that had been inputted into the computer for the responsible party. On 9/22/25 responsible party informed LPA, they also never received any written notification of incident. Regulation 87211(a)(1)(D) indicates :Reporting Requirements: Each licensee shall furnish ..A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident. Continue on LIC9099C2 Continued from LIC9099C: There is sufficient information obtained to support that a violation has occurred regarding the reported allegation of "responsible party not notified of resident fall". Therefore, the allegation is Substantiated. Facility staff not giving prescription medications as prescribed by doctor - Reporting party alleges facility may not have been giving R1 the correct dosages of medications that were prescribed by physician. Facility only had paper Medication Administration Record (MAR) of August for R1 which indicated prescription Rexulti was to be given every AM although does not show was given 8/29- 31/2025. Further review of medications indicated 10 of R1’s daily medications from 8/28-31/2025 were not given consistently. LPA interview with S4 revealed R1 did not have any medication refusals. Interview with Med tech and Administrator informed, with the documents provided they could not confirm medications were provided on said days. As there was no proof medications were provided to the resident, there is sufficient information obtained to support that a violation has occurred regarding allegation Facility staff not giving prescription medications as prescribed by doctor is SUBSTANTIATED . Additionally, Community Care Licensing (CCL) received an incident report on 10/20/2025 indicating on 10/14/2025 while inputting narcotics into new EMAR system discovered R2 had discrepancy in log record. From 8/18/2025 to 10/13/2025 (except on 6 correct occasions) multiple PM med techs had inadvertently been giving R2 PRN Geri-tussin instead of physician ordered routine Guaifen-Codeine. No adverse side effects observed, Responsible party and Hospice physician notified. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of evidence standard has been met. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.