complaint·April 26, 2024

The investigation revealed that R1 activated their call button at 9:17 PM to request care as they had defecated and needed to be cleaned. Staff 1 (S1) responded to the resident and informed them that they could not provide the care at that time as S1 was the only caregiver on duty at that time. S1 was near the end of their shift. S1 reported that they informed the relieving caregiver about R1’s need for care. The care need was not transferred to the next shift in writing violating facility policy. The relieving caregiver did not provide care to R1. R1 fell asleep without receiving care. R1 woke up about and called for care at 3:26 AM and the care staff provided the required care. R1 received care over six hours after their first request for assistance. R1 was left in soiled clothing for an excessive period of time. The preponderance of evidence standard has been met and this allegation is substantiated. A deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8, and is listed on the 9099D. An exit interview was conducted with Jessica Zepeda, Executive Director and a copy of this report, LIC 811, LIC 9099 D and Licensee/Appeals Rights (LIC 9058 01/16) was provided.