complaint·November 17, 2025

(Continued from LIC9099 2 of 3) Staff 2 (S2) was interviewed and stated that the R1 did not notice any changes with R1. S2 stated R1 was at baseline. Staff 3 (S3) was interviewed and confirmed that there was no hydration monitoring in place for R1, but hydration is offered during activities, medication pass and at all meals.  S3 stated that they rely on caregivers to report concerns to the medication technologist, who report any changes to the medical physician. Interviews with three (3) residents were conducted, and they did not express any concerns regarding hydration. LPA observed residents in the dining room during activities, meals, and snacks, and fluids were being offered to residents. Residents who needed assistance were being assisted with drinking fluids. Outside Source 1 (OS1) was interviewed and stated that R1 had experienced multiple episodes of unresponsiveness, vomiting, and shallow breathing while at the facility.  OS1 raised concerns about R1’s hydration status, and requested staff to ensure R1 was receiving adequate fluids. OS1 communicated to the facility that R1 had been hospitalized due to dehydration. Outside Source 3 (OS3) was interviewed and stated that the facility did do their due diligence with sending R1 to the hospital when there were episodes of unresponsiveness, vomiting, and shallow breathing while at the facility. A review of facility records and incident documentation for R1 revealed that the facility did not document if the resident was refusing hydration therefore there was no means of tracking if the resident received adequate hydration. According to a progress note dated 01/21/2025, OS1 reported that R1 had been hospitalized and diagnosed with dehydration. (Continued from LIC 9099C 3 of 3) The Department has investigated a complaint with the above allegation. The Department has found that there is a preponderance of evidence to prove that the alleged violation did occur; therefore, the allegation is substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.