complaint·October 2, 2025

Interviews with R1, staff, and outside sources revealed that R1 was also unable to reposition while in bed and skilled nursing paperwork dated September 2024 revealed that R1 needed to be repositioned every two hours. Interviews with staff and R1 revealed that staff did not initiate repositioning for R1 and instead, R1 had to request assistance with transferring and repositioning, which R1 did not request very often. Interviews with staff and R1 revealed that R1 was receiving wound care from an outside agency in January 2025, however, staff did not have knowledge regarding the name of R1’s outside agency, the frequency of the visits, or specifics regarding R1’s health. Additionally, interviews revealed that the outside agency stopped services in approximately May 2025, due to R1’s pressure injuries being resolved. However, interviews conducted in September 2025 revealed that R1 had at least one pressure injury that was not being treated by an outside agency. Interviews also revealed that facility staff were providing care for R1’s pressure injury. Review of Resident 2’s (R2) assessment records dated July and August 2023 revealed that R2 was bedridden, had a history of skin breakdown, required assistance with all activities of daily living including repositioning every two hours, and was receiving hospice services. Staff stated during interviews that R2 did not have any pressure injuries, however, R2’s hospice care plan dated August 2023 contradicted this information and stated that R2 had multiple Stage 3 and Stage 4 pressure injuries. Interviews with staff revealed that R2 would be repositioned during the day but R2 would not be repositioned overnight. Staff estimated that R2 would be repositioned around 8:00pm and would not be repositioned until the next morning at around 7:00am, which resulted in R2 not being repositioned for approximately 11 hours. Interviews with residents confirmed that there were no awake staff at the facility overnight and staff did not conduct regular rounds or checks on residents overnight. Review of R2’s hospice care plans in 2025 revealed that R2 still had multiple pressure injuries and R2’s hospice nurse care notes revealed that R2 developed a new pressure injury in late August 2025, however the paperwork did note the stage of the new or already identified pressure injuries. Interviews revealed that on at least one occasion in January 2025, a staff member working the afternoon shift left the facility before the overnight staff member arrived, resulting in the facility not having any staff supervision for approximately five (5) minutes. Interviews with staff and residents revealed that there were issues with one specific staff member, Staff 1 (S1), giving residents the wrong medications. Residents denied consuming medication that was not prescribed to them due to residents identifying the incorrect medication and informing staff of the mistake. Continued on LIC9099-C page... Interviews with staff and residents confirmed that S1 was no longer working at the facility as of mid June 2025. [Staff were provided with LIC811 Confidential Names List to identify residents and staff] The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies regarding neglect, absence of supervision, and medication administration are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D pages. Additionally, review of past citations issued within a 12 month period revealed that the facility was cited for absence of supervision on 11/19/2024. Therefore, a civil penalty in the amount of $1,000 was issued for a repeat zero tolerance violation within a 12 month period and noted on the attached LIC421IM form. Additionally, the Department has determined that the allegation of neglect resulting in pressure injuries resulted in injuries to a resident in care, therefore, an immediate civil penalty in the amount of $500 is being assessed and noted on a separate attached LIC421IM form. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report, the two LIC421IMs forms, and the Licensee Appeal Rights (LIC9058 03/22). Additionally, interviews with residents and outside sources stated that some residents would purchase meals while out in the community or would purchase food items if residents did not want to eat the meals cooked by staff. It was alleged that staff did not treat residents with respect. Interviews with staff and residents revealed that at least one resident, Resident 1 (R1) would get upset with staff and yell. Interviews revealed that R1 would also yell during personal care due to pain. However, interviews with outside sources revealed that R1 would get upset and interviews with R1 revealed that R1 had a health condition which could cause R1 to have emotional outbursts. While interviews with R1 alleged that staff did not treat residents with respect, other residents did not corroborate the allegation that staff did not treat residents with dignity. Additionally, staff denied cursing, yelling, or treating residents disrespectfully during interviews. The Department has investigated the above-mentioned allegations and based on interviews and observations, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).