Complaint·November 10, 2025

(Cont. from LIC 9099) R1s Plan of Care for 09/29/2023 stated staff is to assist with toileting activities and assist with peri-care. This information was verified by RSD who stated what this information means is when a resident calls or pushes their button to be taken to the bathroom the caregiver would have to wait outside the door or close it or have it opened but be there to assist. R1s Plan of Care wasn’t changed until 10/01/2024, which required staff to conduct two-hour rounds to offer and ask R1 if he/she needed to be changed and to assist getting to and from the bathroom. On the new Plan of Care, to mitigate future falls the facility had increased safety checks. The facility staff knew R1 was a risk for falls and what interventions were needed to prevent reoccurrences. The facility was responsible for the neglect/lack of care and supervision causing R1 to have serious bodily injury as the resident was left on the toilet with no supervision which resulted in R1 falling and sustaining a fracture to his/her left ankle. At the time of the complaint inspection on 11/10/2025, executive director 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 immediate Civil Penalty is being charged and assessed as $500 on the LIC421IM. An exit interview was conducted with Executive Director Tia Surronen-Goodwin, and a Plan of Correction was jointly developed. A copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Goodwin, signature on this form confirms receipt of documents. (Cont. from LIC9099-A) For the allegation of staff did not adequately assist resident with incontinence care needs in a timely manner, RP alleged that many times R1 is left for hours in soiled diapers because the staff is "too busy" or "understaffed". R1 mentioned that there have been times where he/she sits for hours in soiled diapers and staff does not come and help. RP also said that R1 is not in soiled diapers. On a follow up interview, RP did state that R1 had a dirty brief and a caregiver took a few minutes, before caregiver was able to help. Regarding the allegation of staff did not assist in resident with grooming needs, R1 rarely gets his/her teeth and hair brushed, as well as washing face. R1 said will sit for hours, and no one comes and checks, they don’t brush R1s hair or offer a washcloth. At the same time while the interview was being conducted, a caregiver came in with a washcloth and cleaned R1s face. For the allegation of staff did not assist resident with mobility needs, RP alleged that there isn't always qualified staff members on hand that can get R1 in and out of bed and to the restroom. RSD mentioned that caregivers monitor R1, conduct hourly rounds to ensure R1s safety, and give assistance as needed. Another staff member, S3 mentioned that when he/she takes care of R1, S3 will change R1s diaper every two hours while R1 is in bed, if R1 needs to use the toilet S3 will help R1 to R1s wheelchair take R1 to the restroom. S3 also added that R1 has never gotten out of bed on R1s own, R1 usually uses the pull cord when he/she needs assistance. (Cont. on LIC9099-C pg.2) (Cont. from LIC9099-C pg.1) Regarding the allegation of Staff did not provide assistance for resident to participate in facility activities, RP stated that R1 is left limited to the bed and deprived fresh air or going outside. R1 doesn't get much interaction with other residents or participating in any activities. According to ADM, R1 refuses to join activities. Every morning, the activities team go to rooms and ask residents to join activities. RP shared that R1 doesn’t want to get out of bed and gets anxiety if R1 leaves the room, R1 would rather be on the computer. Based on interviews, observations and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Tia Surronen-Goodwin, and a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Goodwin, signature on this form confirms receipt of documents.