complaint·February 20, 2025

Continued from LIC9099 resulting in pressure injuries. The investigation revealed that R1 required surgery for the sacral decubitus ulcer they obtained while being isolated for Covid-19. Resident passed away approximately one month later from End Stage Parkinson’s Disease with significant contributing conditions including Decubitus Sacral Ulcer, Malnutrition, Dementia and Bilateral Heel Ulcers. Based on interviews conducted, document review, and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 During visit conducted on 02/20/2025, LPA observed that there were a total of 12 direct care staff clocked in and on-site. LPA conducted a walkthrough of the facility with Resident Care Coordinator and observed the residents' being served lunch. LPA observed at least 1 to 2 staff members in all five homes. LPA observed that residents appeared to be clean. Homes did not have any strong odors during the walkthrough. Based on interviews conducted and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.