complaint·July 17, 2025

During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA), which is highly contagious. It was stated that Resident 1 was in the facility with MRSA during the month of April 2025. It was reported that Resident 2 was in the facility with MRSA during the month of June 2025. It was stated that initially, staff were not given the information or directive that residents had MRSA . Based on investigation observations, interviews, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Allegation: Staff do not ensure staff are properly trained. During the interview process, the Administrator, Wellness Services Director and several staff persons were interviewed. Documents were obtained to include Physicians Reports, Emergency Information, Appraisals and Needs, Admission Agreements, hospital notes, staff person names and contact numbers. During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). It was stated by several persons that the medication technicians and care providers were not provided with training regarding providing care and supervision with residents that have MRSA. It was reported that management gave a verbal instruction; however, no formal training. Training did not include documentation from an appropriately skilled professional stating what aspects of care will be delegated to facility staff responsible for the care and that the appropriately skilled professional will train those staff persons prior to delegating care. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Report Continued on additional LIC 9099-C Allegation: Staff do not ensure facility has adequate Personal Protective Equipment (PPE) supplies. During the interview process, the Administrator, Wellness Services Director, and several staff persons were interviewed. Documents were obtained to include Physicians Reports, Emergency Information, Appraisals and Needs, Admission Agreements, hospital notes, staff person names and contact numbers. During the investigation, it was reported that there were two residents (Resident 1 and Resident 2) that were at the facility and diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). Staff were advised to use gloves; however, were not told of the importance to use Personal Protective Equipment (PPE) to include gloves, mask, gown and foot booties. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.