complaint·October 30, 2025

R1’s Appraisal/Needs and Services Plan states “[R1] wears depends, sometimes knows when to use the toilet, [He/She] needs assistance with [his/her] ADLs (Activities of Daily Living) in all times.” On 08/27/2025, the department obtained copies of the facility weekly staff schedules from 07/28/2025 to 08/31/2025. The staff schedules indicate there are at least four staff scheduled each day from 6:00 AM to 6:00 PM, at least three staff scheduled from 6:00 PM to 10:00 PM and one staff scheduled from 11:00 PM to 5:00 AM. Allegation: Staff left resident soiled for an extended period of time During visit on 10/01/2025, LPA Marrufo attempted to interview R1, but R1 refused to be interviewed. On 10/01/2025, LPA Marrufo interviewed witness W1. W1 stated during interview that W1 visits R1 at least once per week. W1 stated to visit R1 for at least three hours at a time. W1 stated to have not observed R1 left soiled for an extended period of time. W1 stated W1 states R1 is sometimes soiled when W1 arrives at the facility to visit R1. W1 stated R1 sometimes resists staff assisting R1 with changing clothes. W1 stated R1 sometimes puts on his/her diapers incorrectly so that the diaper padding is on R1’s stomach. W1 stated R1 does have rashes which W1 believes is from urine contact. During visit on 10/01/2025, LPA Marrufo interviewed staff S1-S6. S1-S3 stated to have not observed R1 left soiled for an extended period of time. S1-S3 stated that staff change R1 every one and a half to two hours. S4 stated to not have observed R1 soiled for an extended period of time. S5 stated R1 prefers to go to the bathroom by himself/herself. S5 stated that R1 has been offered to use a portable chair in the bathroom, but R1 has denied the offer. S5 stated that staff have put padding on R1’s wheelchair and staff clean R1’s wheelchair if it is soaked with urine. S6 stated to have not observed R1 left soiled for an extended period of time. S6 stated staff is always helping R1 go to the bathroom and S6 reminds staff to check if R1 is soaked every one and a half to two hours. Page 2 of 4. On 10/01/2025, LPA Marrufo interviewed witness W2. W2 stated to have visited R1 at the facility to conduct a wellness check on R1 to check on R1’s swollen foot. W2 stated to have observed R1 soaked in urine in R1’s wheelchair. W2 stated there were two staff at the facility and 5-6 residents. W2 stated one of the staff was in the kitchen during W2’s visit. W2 stated to have told one of the staff that R1 was soaked in urine and the staff handed W2 a diaper. W2 stated to not know the name of the staff or remember what the staff looked like. W2 stated to have taken the diaper from the staff and took R1 to the bathroom. W2 stated to have helped R1 change into the diaper in the bathroom. W2 did not provide a date when W2 visited the facility to conduct a wellness check on R1. LPA Marrufo conducted an additional interview with W2 on 10/30/2025, and W2 stated to not be able to recall the date that W2 visited R1 to conduct a wellness check. Allegation: Staff did not ensure resident was dressed appropriately - Unsubstantiated During interview on 10/01/2025, W1 stated to have never observed R1 dressed in only a diaper and shirt. During interview on 10/01/2025, W2 stated to have observed R1 in only a shirt and diapers. W2 stated to not have a photograph of R1 wearing only a shirt and diapers. During interview on 10/01/2025, S1-S6 stated to have never observed R1 dressed in only diapers and a shirt. Allegation: Staff are not providing adequate supervision to residents resulting in inappropriate interaction - Unsubstantiated During interview on 10/01/2025, W1 stated that R1 has a close friendship with R2. W1 stated R1 will sometimes verbally encourage R2 to take a shower. W1 stated R1 has told W1 that R1 will sometimes be in R2’s bedroom, but not in the bathroom with R2 when R2 is in the shower. R2’s shower is inside R2’s bedroom. W1 stated R1 told W1 that R1 will sometimes pick out clothes for R2 and get a towel for R2. W1 stated R1 is not giving a shower to R2. W1 stated to have never observed R1 in the shower with R2. Page 3 of 4. During interview on 10/01/2025, W2 stated that R1 told W2 that R2 provides baths for another resident. During visit on 10/01/2025, LPA Marrufo interviewed staff S1-S6. S1 stated R1 does not assist R2 with bathing at all. S2 stated R1 does not assist R2 with showering at all and is not in R2’s bedroom while R2 is showering. S2 stated R1 does not assist with getting a towel for R2. S3 stated R1 does not assist R2 with showers at all and staff provide R2 with towels. S4 stated R1 does not provide any assistance with showering R2. S5 stated to have not observed R1 shower R2. S6 stated R1 does not provide showers for R2. During visit on 10/01/2025, LPA Marrufo interviewed R2 at the facility while R2’s conservator was listening to the interview via telephone call with the speakerphone activated. During interview, R2 stated staff assist R2 with taking showers. R2 stated R2 takes showers alone and no one is in the shower with R2. R2 stated R1 turns the shower knob for R2. R2’s conservator stated that R2 can sometimes make exaggerated statements. LPA Marrufo asked R2 again if anyone turns the shower knobs for R2 and R2 said no. Based on information from interviews conducted with staff, residents, and witnesses, and records reviewed, although the allegations listed above 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. No Deficiencies were cited under California Code of Regulations Title 22 This report was reviewed with Tyrone Vega and a copy of this report was provided. 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