Complaint·February 8, 2023

(CONTINUED FROM LIC9099) Staff were also educated on the use of a foam wedge to assist R1’s positioning. Staff acknowledged understanding of this on both dates. Interview with R1’s hospice agency staff indicated there was “nothing to indicate that they didn’t understand” however, R1 was “always” lying on their back. Interviews with R1 revealed the resident was not repositioned every two hours. Interviews conducted with facility staff revealed staff turned R1 only once in the morning and once in the afternoon. Based on Community Care Licensing staff observations, interviews which were conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099 D. An exit interview was conducted with AD Gubalane, and a copy of this report was provided along with Appeal Rights.