complaint·July 29, 2025

C1 advised R1 to be careful due to the coffee being hot. C1 stepped away from the living room and went back to work in the kitchen. A few minutes later C1 heard R1 shout. C1 then went to R1 and R1 had spilled coffee on their left arm, left thigh and stomach. It was reported that R1 had fallen asleep with the coffee cup in their hands after not being able to sleep for four nights. C1 then took R1 to the sink to apply cold running water to their left arm and then cold damp cloth to R1’s thigh and stomach. C1 then notified Administrator Maria Sangrador who assessed R1 and observed a small blister on the left arm. Administrator stated she felt she could tend to the wounds as she is a nurse. In the week following, R1 had reported not feeling well and asked to be taken to the hospital. R1 was finally taken to the hospital on January 25, 2025, four days after the incident, due to being lethargic and non-responsi v e. R1 went into respiratory failure and was intubated while at the hospital. R1 was diagnosed with 2 nd degree burns and pneumonia. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations facility staff did not seek timely medical attention for resident and facility staff did not prevent resident from sustaining multiple burns are determined to be SUBSTANTIATED meaning the complaint allegation is valid and that a violation has occurred. See LIC9099-D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 (f) An exit interview was conducted Administrator. A copy of this report, along with LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC 421 IM and the LIC 811, identifying confidential names were provided and explained . Administrator Manuel stated that R1 would not want to wear the machine due to feeling anxious when their face was covered. Interviews with 2 out of 2 staff indicated that the machine was available and working. Administrator stated took the bipap machine to Apria Healthcare in Irvine, CA in May 2025 and technician stated that the machine is working properly. Administrator stated asked company if R1 could get a smaller mask but was told due to fit the larger mask was a better fit for R1. Administrator stated that R1 would use the machine for 10 -15 mins and then switch to oxygen as that made R1 more comfortable. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation facility staff are not ensuring residents medical equipment is properly utilized is determined to be UNSUBSTANTIATED, meaning although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.