complaint·April 24, 2026

Per AD it was only discovered at a later date that R1’s leg was recommended to be amputated which was also listed on LIC 602 Physician’s Report dated 03/20/2023. Per LIC 602 Physician's Report R1 has a history of skin breakdown “extensively on bilateral upper and lower extremities”. Per LIC 624 Unusual Incident/Injury Report received on 04/04/2023 for an incident that occurred on 04/02/2023 it was noted that skin tears were observed by staff for R1/ Per LIC 624 AD notified R1’s responsible party and contacted Home Health for a nurse’s assessment. Per report nurse assessed resident and first aid was applied. Based on interviews with 3 out of 3 staff, staff stated they did not mishandle resident causing skin issues. Residents present during LPA Mendivil’s visit on April 28rd, 2023 were not interviewed as they were either asleep or not oriented to time and space. Per review of LIC 624 submitted to the Department on 04/13/2023 for an incident that occurred on 04/11/2023. Per incident report R1 was sent to UCI hospital due to an unstageable wound and family was contacted after resident was transported using a non-emergent transport. It was alleged that facility staff did not follow R1’s doctor’s orders. Based on interviews with AD there were contradictory orders from R1's physician and Home Health's physician. Based on interviews with staff, staff stated they follow all physician’s orders and interviews. It was alleged that the facility abandoned resident in the hospital, Per interview with AD, AD stated she stayed with R1 while in the hospital on 04/11/2023 and was in contact with R1’s family. It was alleged that the facility did not operate within the terms of their license regarding bedridden residents. Per review of residents’ LIC 602 physician reports, only R1 was listed as bedridden and all other residents were listed as non-ambulatory. Per review of license the facility does have a fire clearance for 1 bedridden resident. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations facility did not properly handle resident to avoid skin issues, facility staff did not notify resident’s responsible party of changes in residents condition, facility staff did not follow resident’s doctor’s orders, facility staff abandoned resident in the hospital emergency room and facility did not operate within the terms of their license are determined to be unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided. Per AD it was only discovered at a later date that R1’s leg was recommended to be amputated which was also listed on LIC 602 Physician’s Report dated 03/20/2023. Per LIC 602 Physician's Report R1 has a history of skin breakdown “extensively on bilateral upper and lower extremities”. AD stated she visits the resident where they are and conducts an assessment. During interview with AD, AD stated R1's leg wound was wrapped and she did not view the wound until the resident was in the facility. Per AD's interview and a summation of the events AD stated that R1 needed a higher level of care. Therefore based on the preponderance of evidence through records reviewed the allegation Facility staff did not properly assess resident before acceptance into the facility is determined to be SUBSTANTIATED, meaning the alleged violation occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report with appeal rights were provided.