complaint·February 24, 2026

(Continued from LIC9099) Hospice nurse (RN) instructed facility staff that every time R1 is found on the floor, they should treat it as a fall and call hospice for further instructions. Hospice was not notified on this occasion and R1 remained on the floor for approximately three hours and forty five minutes. During the interview, S1 said he/she checked R1 for injuries, and did not observe any, and everything looked normal. Another staff, S2, said that S1 told S2 that R1 sustained a burn on the leg about the size of the palm of his/her hand. Hospice was called after. No first aid was administered to R1 and according to Hospice CNA, R1s burn was covered with a bib when CNA arrived at the facility around 12:00 – 1:00 PM. CNA described R1s burn as red with blistering. CNA notified RN and came to the facility to evaluate it around 5:00 PM. Once RN observed R1s wound, RN notified R1s primary care physician and called 911. RN said that type of burn would be very painful, and the coffee had to be very hot to cause that type of damage. R1 went without medical care for approximately 10 ½ hours until paramedics arrived at the facility at 6:05 PM. Based on interviews which were conducted and record reviews, 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 9099D. The Department has determined this violation resulted in Licensee failed to seek medical services for R1 when R1 had coffee spill causing burns in R1s leg. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Currently, according to Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted over the phone with Administrator Melanie Del Rosario as well as Rolando Del Rosario, Rolando Del Rosario,care giver, and a Plan of Correction was jointly developed. A copy of this report, LIC 9099-D, and LIC421IM and the Licensee/Appeal Rights (LIC 9058) were provided to Rolando Del Rosario,care giver, whose signature on this form confirms receipt of documents. . (Continued from LIC9099) Facility staff said R1 will occasionally climb out of bed and voluntarily place himself/herself on the floor. Staff stated R1 will occasionally refuse to get up from the floor, so staff will provide R1 a blanket and pillow and make him comfortable on the floor. According to S1, R1 did not refuse to get off the floor on 10/25/2024, and R1 was left on the floor because S1 was concerned R1 may get back out of bed in the evening. During R1s examination at the hospital on 10/25/2024, R1 had a normal range of motion in all his/her extremities and there was no hip injury discovered. Regarding the allegation of Lack of supervision, resulting in resident sustaining burns, RP stated that the facility staff gave R1 breakfast which included hot coffee that R1 ended up spilling on himself/herself giving R1 the first and second degree burns on his/her leg. R1 has no diet restrictions. R1 can feed himself/herself, and R1 drinks coffee every morning with no prior issues. On 10/25/2024, around 7:30 AM, S1 gave R1 breakfast which included a cup of coffee. S1 left R1s room momentarily and heard R1 yell. S1 returned to the room and discovered R1 had spilled his/her coffee on the right leg and all over the floor. Based on interviews and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Rolando Del Rosario, care giver, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.