complaint·February 24, 2026

(Continued from LIC9099) Caregiver (S1) cared for R1 on 2/8/2025 and 2/9/2025. On 2/8/2025, around 8:30 AM, S1 and S2 changed R1s brief. There was no wound on R1s back upper left thigh at that time. HH also visited R1 at the facility on 2/8/2025, around 10:00 AM, and did not document any new injuries. S1 said he/she checked on R1 the remainder of the shift on 2/8/2025, as well as throughout 2/9/2025. R1 did not do any brief change. S1 left at the end of the shift on 2/9/2025, around 6:30 PM and S2 took over. On 2/10/202, around 8:00 – 9:00 AM, S2 and S3 rolled R1 to his/her side to change the brief. S2 noticed that R1s catheter cord was positioned under R1s left thigh and when S2 removed the cord, S2 observed a large open cut where the cord had been placed. S2 said he/she did not have a co-worker the evening of 2/9/2025 into the morning of 2/10/2025 therefore S2 did not reposition R1 in bed. Based on the interviews, R1s brief was last changed on 2/8/2025, around 8:30 AM. It’s not noted when the last time S1 repositioned R1 before ending the shift on the evening of 2/9/2025, at 6:30 PM. However, S2 did not reposition R1 when S2 took over R1s care on 2/9/202, at 6:30 PM until S2 changed R1 on 2/20/2025, around 8:00 – 9:00 AM, around fourteen hours later. 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 a developed of an open wound due to lack of care and supervision. 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 with Administrator Lindu Napitupula , and a Plan of Correction was jointly developed. A copy of this report, LIC 9099-D, LIC421IM and the Licensee/Appeal Rights (LIC 9058) were provided to Administrator Lindu Napitupula , signature on this form confirms receipt of documents. (Continued from LIC9099) According to HH, R1 was exhibiting symptoms of a UTI the week prior to going to the hospital on 2/10/2025, and a urine sample was taken for testing. The preliminary finding of UTI was delivered to home health on 2/7/2025 and the final finding of a UTI was delivered on 2/10/2025. HH2 added that R1 would have been prescribed antibiotics, however, R1 had been transported to the hospital before the prescription could be ordered. Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Lindu Napitupular, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.