complaint·February 3, 2026

Continued from LIC9099 of the wound. Complainant further stated that they didn't know how or when R1's injury occurred and didn't know if R1's home health agency or primary care physician had been notified. Review of R1’s progress notes showed that on 12/17/2025, facility caregivers observed that R1 had a big wound on their bottom. These notes further stated that the wound was observed to be an open hole, that it looked very bad, and was leaking a white liquid. R1’s nursing progress notes stated the following entries: · On 12/17/2025, a late entry was inputted to note that R1’s home health agency provided wound care with no additional details. · On 12/18/2025, facility notes stated that R1’s responsible party was contacted and that R1’s home health agency was providing wound care three times per week. Per notes, facility would communicate with R1’s primary care physician regarding intervention or in-house treatment. · On 12/20/2025, a late entry was inputted to note that R1’s home health agency provided wound care with no additional details. · On 12/21/2025, the resident care director and health care coordinator contacted R1's Primary Care Physician via a fax communication. Per fax communication, facility asked for further advice as it was believed that R1 had a stage 3 pressure wound and they wanted an update on R1’s hospice referral. Review of R1’s physician fax communication for 12/21/2025 stated that R1 had a wound that appeared to be a Stage 3 and that it was getting worse even though R1 had been receiving home health services. Fax further requested for a status update on R1’s hospice referral as being a licensed facility meant that R1 would need to be receiving hospice services if the facility were to retain a resident with a Stage 3 wound. Interview conducted with Resident Care Director (RCD) revealed that on 12/22/2025, emergency personnel (EMS) arrived at the facility to send R1 to the hospital. Per RCD, no one at the facility contacted EMS on 12/22/2025 and emergency personnel informed them that they received an anonymous phone call for R1. The Department observed that the facility did not request or submit any documentation for an exception for R1 to stay at the facility once it was believed that R1 could have had a stage 3 pressure injury on 12/21/2025. Review of R1's medical records showed that R1 was diagnosed with a Stage 4 pressure injury on 12/22/2025. Continued on LIC9099C Continued from LIC9099 Based on interviews conducted, record review, and observations made, these allegations are Substantiated . A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An immediate Civil Penalty in the total amount of $500 has been issued for not seeking timely medical care (See LIC-421IM). An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).** Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.