Complaint·February 21, 2026

(Cont. from LIC 9099) According to the interviews with facility staff, hospice care staff, and family member, R1 is bedridden and hardly moves while in bed. R1 has never attempted to climb out of bed without assistance and R1 has never been found on the floor after an unwitnessed fall. Hospice nurse, H3 stated he/she does not believe R1 suffered a fall. There is no evidence or witnesses to corroborate the allegation of Neglect/Lack of Care and Supervision resulting in R1 sustaining a fractured left arm. 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 and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Medical Technician Gloria Castro , whose signature below confirms receipt of these rights. (Cont. from LIC 9099) On the evening of 1/13/2025, S2 heard R1 in the room screaming when a caregiver was attempting to change R1s clothing for bed. S2 went to check and noticed R1 had bruising from the left shoulder to the elbow and R1s elbow was swollen. S2 notified hospice of R1s condition. The hospice representative told S2 there was no on-call nurse available to visit R1 and that R1 had a scheduled visit with a hospice nurse on 1/14/2025. The nurse visited R1 on 1/14/2025 and had R1 transported to the hospital to be evaluated. Hospice was notified immediately when R1 expressed pain in R1s left arm and again when bruising and swelling was noticed. Facility staff were directed by Hospice staff to give R1 the prescribed pain medication and did not send a nurse to the facility as requested to evaluate R1. There was the delay as R1 had advised they were expressing pain. Although the facility did contact the hospice agency, the hospice agency advised they can’t come out until the next day and left R1 without medical care after expressing pain. It was not until the hospice agency came and then advised the facility to send R1 to the hospital. The facility should have sought further medical treatment since the resident was expressing pain. At the time of the complaint visit the licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. 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. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Medical Technician Gloria Castro , whose signature below confirms receipt of these rights.