complaint·December 23, 2025

R1’s then private caregiver who reported no such redness was observed. Around the end of June or beginning of July, R1’s responsible party (RP) noticed a small red mark on R1’s heel and brought it to the Licensee’s attention. R1’s RP reported Licensee began putting ointment on the red mark per physician order. Licensee initially confirmed statement regarding ointment but later changed the statement and denied the physician ordering the ointment; Stating instead, that the injury was due to poor circulation. As the RP visited 1-2 times weekly, it was observed that the pressure injury was getting progressively worse. R1’s RP requested Licensee seek medical attention for the pressure injury for R1, but no such medical attention was sought. Text messages obtained from July 7, 2025, to July 30, 2025, show RP repeatedly requested medical attention for the wound from the Licensee. Upon noticing the increasingly worsening condition, R1’s RP made an appointment with Home Base Medical to have one of their physicians visit R1 on June 30, 2025. RP requested that Licensee be present to discuss the pressure injury as RP was unable to make the appointment. During the appointment, it is unclear as to whether the pressure injury was brought to the physician’s attention as the Doctor denied being advised of the injury as well denied recommending any treatment for the pressure injury when interviewed. However, Licensee provided a note written with the attending physician’s signature indicating difficulty obtaining care due to the resident’s behaviors. While the physician confirmed they had signed the note, they reported they did not write the contents of the letter as that had been provided by Licensee. Per interview with Licensee, Licensee reported R1 was not seen by a medical doctor due to insurance issues and ongoing behavioral issues related to the resident’s diagnosis. During interview with the Department, Licensee stated a pressure injury was not a reason to go to the urgent care or Emergency Department. Licensee confirm witnessing an occurrence when R1 was being fed large chunks of meat by a caregiver without the dentures inserted. Licensee indicates there was no glue on-site for the dentures. RP denied ever receiving a request for denture glue from Licensee. Two out of two witnesses confirm Licensee later inserted R1’s dentures after it was brought to her attention, however, after the dentures were inserted, big chunks of meat continued to be forced into R1’s mouth. On July 31, 2025, the resident was removed from the facility by their RP. R1 was assessed for hospice care on August 07, 2025, after moving out of the facility. Hospice documentation notates that due to minimal activity and increased weakness, R1 developed pressure ulcers on the left and right foot. The diagnosis is deep tissue injury on the left lateral foot and stage 3 pressure injury on right lateral foot. On November 21, 2025, R1 passed away. Based on interviews conducted and record review, there is sufficient evidence to substantiate the allegations. Therefore, the preponderance of evidence standard has been met, and the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. CONT ON LIC 9099C DATED 12/23/2025 A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted, and copies of this report, LIC 9099-D, Appeal Rights, Immediate Civil Penalty Assessment, and LIC 811 (Confidential Names) were provided to Licensee at the conclusion of the visit.