Complaint·July 11, 2025

R1 stated Ombudsman wanted to review their medical information due to a discussion had between R1 and the Ombudsman on June 30, 2025. R1 stated they later rescinded the consent verbally over the phone with the Ombudsman hours after the Ombudsman left the facility. LPA interviews with two out of two staff interviewed stated during the visit on June 30, 2025, the Ombudsman asked to view R1's medical records. Two out of two staff stated they declined to provide medical records to the Ombudsman even with R1's written consent. One out of two staff added they told the Ombudsman they needed consent from R1's family member in order to provide R1's records. Ombudsman along with Staff 1 (S1) called the Department's duty line to discuss the matter and spoke with LPAs Garlli Tat and Kevin Saborit-Guasch during the Ombudsman visit at the facilty. Both on duty LPAs explained to S1 that in the absence of a conservatorship, R1 could agree to share their personal information with the Ombudsman as part of their duties at the facility. S1 acknowledged that after the phone call with the on duty LPAs, S1 still declined to share R1's medical record with the Ombudsman while the Ombudsman was at the facility. The Ombudsman never obtained R1's medical records. LPA record review of R1's file did not indicate a conservatorship nor any power of attorney documents in place. Regarding the allegation staff did not properly sanitize the facility, it was reported there is a strong urine odor at the facility. LPA Arias observed a lingering urine odor coming from the living room. LPA observed a very strong urine odor coming from Resident 2 (R2)'s room. LPA interview with staff 2 (S2) stated R2 is not cognitive and urinates on different places in the room including on the wood floor. R2 has to be redirected to use the bathroom. LPA observed some of the wood flooring has warped in R2's room. S2 stated they mop the floor often but that does not remove the urine odor. Based on LPA interviews, observations, and record review, the preponderance of evidence standard has been met. Therefore, 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. An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.