complaint·February 12, 2026

(Continued from LIC9099) R1, was wheelchair-bound, required total assistance for all activities of daily living, followed a pureed diet, exhibited behavioral disturbances, and had a catheter in place incrementally. R1 was also was transported daily to a healthcare facility for insulin care. Department review of email correspondence reveals on June 6, 2025 the facility reported observing blood drops from the R1's genital area during a brief change and notified R1's clinic. On June 17, 2025, the facility emailed the clinic reporting a skin tear near the catheter site. The clinic responded with instructions to clean the area, adjust the catheter securement device to reduce tension, and monitor the resident, noting that the resident was on blood thinners. Department review of the facility’s Unusual Incident/Injury Report dated June 24, 2025, revealed on June 24, 2025, the resident attended a routine appointment at R1's clinic, the facility documented receiving a call from the clinic nurse stating that trauma related to the catheter was observed and the resident was sent to the hospital for further evaluation. Department review of hospital records dated June 24, 2025, revealed the resident was examined for a genital injury and diagnosed with erosion of the urethra related to catheter use. The documentation does not reference external trauma or abuse. Department review of Training Log dated, 05/29/2024 revealed staff had training on Skin care and pressure ulcer training and staff also received instruction on proper catheter care procedures and communication protocols to ensure compliance with care standards. Facility records show staff communicated with clinic and family regarding catheter care, followed instructions provided, and reported the incident to CCLD as required. Based on interviews and document review a preponderance of evidence does not exist to support the allegation that staff abused a resident resulting in serious bodily injury. The allegation is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.