Complaint·February 19, 2025

LPA Donato interviewed a staff member. S1 shared that they are often working with alone with 5-6 residents and that they have been in a situation where a resident was slipping to the floor from the chair and was unable to pick the resident up but because S1 was working alone. The staff have difficulty addressing the other resident’s needs, for example, if a resident needs their help to walk to the bathroom but they cannot get to them in time and they soil themselves. LPA interviewed R1. It was shared that most of the time he/she had to wait to be assisted in the morning. R1 mentioned that it was already brought up, but nothing has changed. R2 & R3 were also interviewed and said that staffing is ok. They are being helped if needed. However, these two residents are able to ambulate with minimal assistance. LPA also observed that there is only one staff scheduled from 7-9am preparing breakfast and then starting with morning care for 5 residents. LPA also observed that S1s back was wet with urine when being assisted by a staff that started at 9am. S1 was soaked with no timeline as to when it started. LPA also obtained photos of R1 soaked in urine because staff was not able to change R1 on time. Regarding the allegation of Licensee did not ensure that resident received medical attention in a timely manner, RP stated that a staff had texted the Licensee to let them know that one of the residents was complaining about burning upon urination. S1 tested the urine and it was positive for UTI. It took Licensee 2 days to get back with S1 and then asked to call the MD for an antibiotic prescription. LPA interviewed R1 and it was confirmed that it took days before R1 was able to talk to the doctor. S2 also confirmed that it did took them 2 days to call the doctor. Therefore, based on the interviews conducted and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed. A copy of the report and appeal rights are provided. page 2 of 2