Complaint·February 13, 2026

{9099-C-2} The care plan for R1, written by Administrator Grace Quierez, noted that primary care staff will be instructed maintain proper medication, encourage resident for daily activities and range of motion, in addition to “Instruct facility staff and primary caregiver to observe patients’ skin during bathing and toileting”, and position pillows to prevent pressure and skin to skin contact. Per record review and interviews, a review of the Preplacement Appraisal dated 8/20/2023 for R1 indicates 2-person assist is needed for bathing, and toileting. Facility was unable to show they repositioned R1 on a regular basis and there was no plan in place to ensure residents are rotated and checked for developing pressure injuries. Medical records show R1’s wounds got worse overtime, and necessary medical attention was not obtained. R1’s primary cause of death is septic shock due to stage 4 pressure wounds. It was corroborated by S1, S3, and S4 that care staff did not notify the Licensee or Administrator when the pressure injuries were noticed nor did they activate 911. Facility did not ensure staff were properly trained in Pressure Injuries. Per interviews and record reviews, it was learned that S3 noticed R1’s pressure injuries on 08/26/2025 and attempted to clean the wounds themselves prior to notifying the Licensee on 8/28/25. S4 was also aware that R1 had developed pressure injuries prior to 8/28/25 Per, R1s Personal Rights for RCFE dated 08/26/2025, Gene-Lyn Guest Home, Inc. must provide continuous care and supervision and if there are any changes in R1’s physical, mental, emotional, and social functions, the facility must notify the resident’s family, physician, and other appropriate people. A hospital physician (W1) explained that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gene-Lyn Guest Home, Inc. Interview with a Witness 2 (W2), revealed that upon R1’s hospitalization, R1 was found to have multiple pressure injuries. W2 stated that some gauze in R1’s lower back wound, they stated It “...seemed like someone was trying to clean the wound but was inexperienced”. A review of R1’s medical records obtained from the hospital confirmed the presence of multiple pressure injuries that had developed for “weeks” leading up to R1’s death on 9/1/25 and the primary cause of death was stage 4 pressure injury ulcers. Based on the above noted information, the allegation that a “Resident developed multiple pressure injuries due to neglect by staff” is substantiated. {Continued on 9099-C-3} {9099-C-3} The following has been determined as it relates to the aforementioned allegation: Staff are not properly assist residents with their dental needs Regarding the allegation “Staff are not properly assist resident with their dental needs”, the investigation consisted of interviews and records review. LPA Tamayo observed that R1’s Admission Agreement for RCFE dated 08/23/2023 indicates the facility will aid with Residents’ dental and medical care appointments and transportation for appointments. Records show Dental care visits were not provided for R1 in the last 12 months. The facility did not have records of daily dental care available for review. On 9/16/25, LPA Tamayo interviewed family member for another resident (R3), in which it was reported R3 was missing a lot of teeth, and they had more teeth at move in days prior. Per record review and interviews, the pre-admission appraisals dated 8/20/2023 indicated 1 person assist will be provided for oral care on a daily basis. Additionally, per R1's Personal Rights for RCFE dated 08/26/2025, Gene-Lyn Guest Home, Inc. must provide continuous care and supervision and if there are any changes in R1’s physical, mental, emotional, and social functions, the facility must notify the resident’s family, physician, and other appropriate people. Based on the above noted information, the allegation that staff are not properly assisting residents with their dental needs is substantiated. The care plan for R1 noted that primary care staff will be instructed to brush their teeth two times a day and maintain proper medication. Based on the above noted information, the allegation that “Staff are not properly assist resident with their dental needs” is substantiated. Based on the above noted information, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.