complaint·March 20, 2026

(Continued from LIC 9099) It was alleged that Staff left resident in soiled diaper for a period of time. Staff interviews reported that the routine was to check R1's diaper at 6am. R1 would be bathed by the hospice bath aide between 7-8:30am and breakfast would be at 9am. After breakfast R1 would "walk" in the wheelchair outdoors if weather permitted. After lunch the diaper would be checked and R1 would take a nap. R1 would awaken before dinner and, after dinner, R1 would return to the bedroom to watch television. Staff reported R1 did not have any rashes and did not sit in soiled diapers. Staff tried to keep R1 busy throughout the day so R1 would sleep better at night. R1 would be restless and get out of bed at night. The allegation that Staff left resident in soiled diaper for a period of time is Substantiated. R1 changed hospice agencies on December 29, 2025. On January 1, 2026, a witness stated R1 had a soiled diaper from 6am. The witness arrived at 9am and asked staff why R1 had not been changed. AD stated they had expected the hospice bath aide, who normally arrived between 7:30 to 8am. The facility reached to the hospice agency and were told the aide had called off and someone would be arriving. The bath aide did not arrive until noon. Two of two witnesses confirmed the allegation that Staff left resident in soiled diaper for a period of time. Two of three staff confirmed the allegation but one staff member was not present and could not confirm nor deny the allegation. Based on LPA record review and interviews, the preponderance of evidence standard has been met. Therefore the allegation that Staff left resident in soiled diaper for a period of time is Substantiated. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Lorna Smith, Administrator and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 9099-D and Appeal Rights. ***This is an amended report.***