Complaint·January 16, 2026

R1’s Physician’s Report dated 11/29/2021 indicated R1’s had motor impairment/paralysis, and was unable to bathe, dress/groom, and transfer to and from bed. R1’s Resident Appraisal dated 09/27/2021 indicated R1’s overall health appears fair and required a dialysis diet. It also showed that R1 required assistance with the following: transferring in and out of bed; toileting; dressing; bathing; hair care; personal hygiene; help with moving about the facility; medication management; and help in participating in activities. Also, R1 was receiving dialysis three times a week. The administrator’s interview confirmed that R1 was receiving full service for activities of daily living. The facility’s Body Check form for R1 dated 09/27/2021 indicated R1 had scars on their left arm from dialysis and a small ulcer on left side ankle/dryness in both feet and toes. R1 was supposed to receive a shower once per week. However, staff were not providing a shower to R1 as the wound had been observed by staff. R1’s Admission Agreement (AA) dated 09/27/21 indicated R1 was a Level 4. Level 4 identified on the AA which reflected the following services: escort AM/PM; bathing; dressing; grooming; and 2hr checks. R1’s medical records indicated R1 was evaluated by their Primary Care Physician (PCP) on 7/15/2022. At that time R1 had a 1x1.5cm ulcer at the base of their left fourth toe with discharge present. One-week history of blister of left foot with progressed pain, at a high level, not relieved by pain medication. Skilled nursing was ordered for wound care. R1 skipped dialysis twice in one week due to left foot pain. R1 had shaking chills and had not been receiving would care at their facility. There was a vast increase in size of the wound of left foot from 5cm ulcer at base of left toes, dorsal surface, induration/discharge/foul odor/soiled dressing present. Concerns of sepsis with high risk for amputation, PCP called 911 and transferred care to Emergency Medical Services. A further review of R1’s medical records indicated the chief complaint for the hospitalization on 07/25/2022 was for leg pain with bacterial skin infection on left foot. The wound on R1’s left foot was classified as Class IV wound- dirty or infected is a classification for surgical wounds that are significantly contaminated. The report also stated the large, infected wound on the left foot extended from the plantar to the dorsal aspect. In addition, the report indicated that the foot is swollen, there is a foul-smelling oozing open wound over the MTP joints from T2-T5, there are some maggots seen on the lateral aspect of the wound. A left below-knee amputation surgery was performed due to nonhealing infected left foot wound, peripheral vascular disease. Staff interviews confirmed R1 had a change in condition. Staff stated when R1 first moved in, they were “half-independent”. R1 used both wheelchair and walker at the facility, was active and able to propel themselves in their wheelchair. R1 was also able to use the bathroom independently. Once R1 became less independent, diaper changes were provided. However, the facility did not conduct the required reappraisal when R1 had a change in condition and/or obtained a current Physician’s Report. The Care Coordinator’s (CC) interview confirmed there was a change in condition when the CC went to a nursing home to assess R1 after the leg amputation and bring R1 back to the facility. The CC stated R1 needed help with transferring from bed to wheelchair and became a two-caregiver assist. The reappraisal was not conducted for R1. Resident interviews confirmed they observed maggots on R1’s leg due to a leg infection, along with a bad odor, and reported it to staff. The administrator confirmed R1 was not receiving home health services prior to 7/26/2022. The administrator explained R1 was being treated for the wound by their PCP, and it was up to the PCP to determine and order home health for wound care. Administrator further stated that if home health was pending/resident waiting, then they can get involved and assist. Also, if a resident’s situation got worse fast, staff would send the resident out to the hospital for treatment. PCP’s interview stated they attempted to get R1 skilled nursing services, as it’s the PCP’s responsibility. However, R1’s medical insurance was very limited and difficult, it never went through. PCP also suggested many times to R1, to transfer to a skilled nursing facility where their needs would be better met. However, R1 declined to move and stated they liked it at the facility. In addition, the PCP said they asked R1 many times to send R1 out to the hospital as they could not get home health or other care needed, but R1 declined offers. PCP explained they did not provide any instructions to staff once the infection was identified due to staff not having any nurses or staff that were trained or qualified to change and care for the wound. The facility staff failed to provide adequate care for R1 which resulted in a serious medical condition. Based on LPA’s observations and interviews which were conducted and record review, 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. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Rocio Granda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1] A civil penalty in the amount of $500 was assessed per Health and Safety Code 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1. Determination of Civil Penalties under Health and Safety Code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Rocio Granda whose signature below confirms receipt of these rights.