complaint·January 30, 2026

In addition, records indicated that R1 did not have capacity for self-care in areas including bathing, dressing, incontinent care, and medication administration. R1 was non-ambulatory, used wheelchair, and needed help with transferring, moving about facility. Also, R1 needed special observation/night supervision. Based upon further records review, there was no written record of the care R1 would be receiving in the facility. The written record of care would have included how facility would provide care to meet R1 care and observation needs. During the investigation, it was revealed that on or around June 13, 2025, R1 was observed with reddened area on tailbone (sacral area). Several facility staff, including administrator, acknowledged awareness of reddened area on R1 on June 13 th , 2025. It is not indicated how long the reddened area was observed prior to June 13 th , 2025. From around June 13 th , 2025, until July 16, 2025, the reddened area on R1 sacral was not assessed by physician nor skilled medical professional. Facility staff acknowledged that during this time, the area was being treated with ointment, not authorized by physician or skilled medical professional. Responsible party of R1 was made aware of the “worsening” of the reddened area on July 12 th , 2025. This prompted the responsible party, not facility staff, to make contact for medical assessment. When the area was assessed by medical professional on July 16 th , 2025, it was found that R1 had an unstageable pressure injury. Per Title 22 regulations, "Pressure Injury" means localized damage to the skin and/or soft tissue under the skin that is usually over a bony part of the body or related to a medical or other device. This damage can appear as intact skin or an open ulcer and may be painful. It occurs as a result of intense and/or prolonged pressure on the affected part of the body or pressure combined with shear (an action or stress that causes internal parts of the body to become deformed). Based on appearance and severity, the damage to tissue is a Stage 1, 2, 3, or 4 pressure injury.” Unstageable pressure injury, according to the Mayo Clinic, is “an unstageable pressure ulcer (or bedsore) is a full-thickness skin and tissue loss where the wound bed is obscured by dead, yellow, brown, or black tissue (slough or eschar), preventing healthcare providers from determining the true depth and extent of the damage until that tissue is removed. It's considered a serious injury (Stage 3 or 4)………”. Based upon Department investigation, the allegation that due to staff neglect, R1 sustained an unstageable pressure injury is substantiated. Facility staff did not ensure that R1 received the care needed and identified in facility records. R1 was admitted to facility with no pressure injuries. R1 had history of skin condition or breakdown. However, no written record of care was documented to include how facility would provide care and observation to meet R1 needs. Prior to or around June 13 th , 2025, R1 developed reddened area on sacral area, but facility staff neglected to obtain appropriate assistance for care. The area continued to worsen and then R1 was diagnosed with unstageable pressure injury to the area on July 16 th , 2025. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Administrator Arjan Marlo Banez. Additionally, On August 08, 2025. The department received a complaint in regards to facility staff retained a resident with a prohibited health condition. Through interviews, it was revealed R1 had an unstageable pressure injury, which is a prohibited health condition in Title 22 Regulations. The department observed the facility staff did not attempt to relocate or notify department of prohibited health condition. The finding is substantiated A deficiency is being issued per California Code of Regulations, Title 22. Furthermore, on August 08, 2025 the department received a complaint regarding facility staff not notifying authorized representative of change in condition. Interviews revealed R1’s responsible party was made aware of pressure injury on 07/12/2025, however, facility staff stated R1’s responsible party was made aware of pressure injury on 06/13/2025. The department determined there is not sufficient evidence to support R1’s responsible party was informed of change in condition of R1. A deficiency is being issued per California Code of Regulations, Title 22. Moreover, on August 08, 2025 the department received an additional complaint regarding untrained staff treating a pressure injury. Interviews revealed that facility staff confirmed to treating R1’s reddened area/stage wound with ointment that was not ordered from hospital or physician. Additionally, interviews and observations disclosed no documentation of turning or repositioning R1. The finding is substantiated. A deficiency is being issued per California Code of Regulations, Title 22. On August 8, 2025, the Department received a complaint with allegation of personal rights violation which contributed to R1 death/questionable death. The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals. R1 relocated from facility on July 18 th , 2025, and subsequently passed away on August 1 st , 2025. The sacral pressure injury was identified as condition contributing to R1 death. Based on the investigation, there is preponderance of evidence to support that facility staff neglected R1. Specifically, it was found that from around June 13 th 2025, until July 16 th , 2025, staff did not provide R1 with care and services to meet their needs. During this time, R1 sustained an unstageable pressure injury and subsequently passed away. The allegation that facility staff neglect contributed to R1 death/questionable death is substantiated. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Administrator Arjan Marlo Banez.