Complaint·October 14, 2025

. LPA observed an incident report dated October 6, 2025, stating that R1 was sent to the hospital on October 4, 2025, due to weakness and feeling sleepy. LPA observed a physicians order for a urinary analysis sample to be done for R1 on September 30, 2025. Interviews with staff 2 of 4 staff revealed that R1 had bed bugs in their room that were treated by facility staff. 2 of 4 staff revealed that they did not call a pest control company, but took care of the problem internally. 2 of 4 staff revealed that to their knowledge the facility is free of bedbugs at the time of the investigation. 1 of 4 staff informed LPA that another room previously had bedbugs about a month ago that has since been eradicated. LPA toured the facility with staff and observed R1s room had no bedbugs on the bed or wheelchair. LPA observed an insect with Staff 1 (S1) that was found in R1s closet. LPA observed R1s room to be cleaned and given a new mattress that is in a mattress cover. Interviews with 4 of 4 staff revealed that R1 was in the hospital at the time of the investigation. 3 of 4 staff informed LPA that R1 was sent to the hospital on October 4, 2025, due to an UTI suspicion. 3 of 4 staff informed LPA that on September 30 , 2025, it was brought to staffs attention that R1 had a foul smell in their urine. Facility staff called R1s responsible party and physician. 3 of 4 staff informed LPA that R1 was delayed getting a sample due to R1 refusing to provide a urine sample and then once obtained the sample expired before it could be sent to the lab for testing. 3 of 4 staff informed LPA that R1s responsible party requested for R1 to go to the hospital due to it being days since suspicion and nothing had been accomplished. Based on observation, interviews, record review and information gathered during the investigation, 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 are being cited on the attached LIC9099D. An exit interview was conducted with AD and a copy of this report, LIC9099D and appeal rights were left at the facility.