Follow-up on corrections·August 5, 2025

On 8/5/2025 at 8:10am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a case management visit. LPA met with Administrator Edwin Ingan and explained the purpose of the visit. During a recent complaint visit to the facility LPA noted during file review and staff interviews that Resident #1 (R1) moved into the facility in January 2025. It was alleged that neglect from the staff caused R1 to sustain a pressure injury on their left foot. Staff stated R1 moved into the facility with the pressure injury and the administrator stated they noted the pressure injury on 1/10/2025 when assisting resident with shower. Staff stated they did not document the pressure injury and the review of R1’s file revealed no documentation of the pressure injury. LPA record review of home health records reveal nurse notes during a visit to R1 on 1/17/2025 note two wounds on R1’s left heel. Per Title 22 regulations facilities are required to document when changes such as a physical health condition is observed. Since the facility did not document when the wound’s on R1’s left heel were observed it is difficult to determine when and where the pressure injuries developed. Based on interviews conducted and record review, the facility did not document an observed change to R1’s physical health. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited on LIC809-D. Exit interview conducted, appeal rights and copy of this report issued.