complaint·April 29, 2026

Allegation: Neglect/Lack of Care and Supervision – Resident developed a pressure injury while in care due to staff neglect It was alleged that resident #1 (R1) developed a pressure injury while in care due to staff neglect. Records reviewed, including facility documentation and medical records, indicate that R1 had a history of medical conditions that placed R1 at high risk for skin breakdown. Documentation shows that the pressure injury was being treated by facility staff, as well as outside providers including home health nurses and wound care specialists. Medical records further indicate that the wound was actively managed by the facility in coordination with Kaiser Permanente. The home health agency reported no concerns regarding neglect during their visits. The coroner’s report noted no evidence of abuse, neglect, malnourishment, or suspicious circumstances. Documentation shows that when the pressure injury did not improve, the facility arranged for hospital evaluation and placement in a skilled nursing facility. Interviews conducted with residents did not reveal concerns related to neglect or abuse. Residents reported that staff responded to requests for assistance in a timely manner. Therefore, the allegation is Unsubstantiated . Allegation: Facility charged resident for a service they did not receive. Based on the interviews conducted with the residents and staff, it was confirmed that the facility does not charge the residents for any services not received, therefore the allegation is unsubstantiated. Based on the evidence obtained during the Department’s investigation, there is insufficient evidence to support the allegations. Although the allegations may have occurred or may be valid, there is not a preponderance of evidence to establish that a violation occurred. Therefore, the allegations are deemed Unsubstantiated . An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and provided to executive director Monique Del Junco.