complaint·April 15, 2025

S3 stated they assisted R1 with bathing, clothing, diaper changes, feeding and checked R1 every two to three hours. S3 denied there was a care log to keep track of the care and services provided to R1. During this investigation, the department made several attempts (dated January 12, 2024, January 17, 2024, January 18, 2024 & January 22, 2024) to reach S4 but was unsuccessful in reaching S4. All three staff members (S1, S2, S3) confirmed that S4 no longer works for the facility. All three staff denied R1 had home health services while in care at the facility. The department conducted interviews with five witnesses. One witness (W1) revealed on September 17, 2023, W1 observed R1’s buttocks was red and had black dark spots. Other witnesses (W2 and W3) denied being aware of R1’s pressure injury while in care at the facility. On September 19, 2023, S1 stated R1’s vital signs were checked and found that R1 was not in good condition, 911 was called and R1 was taken to Providence St. Jude Medical Center. R1 was admitted to the hospital for multiple medical conditions and hospital staff discovered the pressure injury on R1. Per review of hospital records and photos, it was revealed that R1 had multi-medical problems including an unstageable coccygeal decubitus ulcer . That was confirmed by a Medical Consultant II of the Division of Medi-Cal Fraud and Elder Abuse, Office of the Attorney General, Department of Justice, who specializes in Elder Abuse who reviewed R1’s medical records. On September 22, 2023, R1 was admitted to hospice at Providence St. Jude Medical Center. R1 deceased at the hospital on September 23, 2023 due to cardiopulmonary arrest, sepsis, urinary tract infection and metastatic ovarian cancer per death certificate dated September 28, 2023. It was revealed that R1’s cause of death was unrelated to pressure injury. Based on observations, interviews and records reviewed, the preponderance of evidence has been met, the allegation, “Resident developed a stage 3 pressure injury while in care due to neglect” is SUBSTANTIATED. An Enhanced Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An Immediate Civil Penalty is being assessed. An exit interview was conducted with Administrator Song, and a copy of this report, 9099-D Page, Copy of Civil Penalty Assessment Form and appeal rights was provided. During visit on 10/5/2023, LPA Tirre observed 13 staff members present and assisting residents with meals and activities of daily living. LPA Tirre did not observe any health and safety risks of residents in care during investigation. Based on staff interviews and observations the allegation facility lacks staffing to meet resident’s needs is deemed UNSUBSTANTIATED. Based on the information gathered through interviews and observations, there was not a preponderance of evidence to prove or disprove that the Facility lacks staffing to meet residents needs. An exit interview was conducted with Administrator Michelle Song and a copy of this report was provided to facility