complaint·February 3, 2026

Continued from LIC9099... The seventh staff interviewed indicated the pendant was ringing and staff responded to it. Interviews of management revealed that R1 returned the morning of September 4, 2025, to the facility from an ER visit for a UTI the day prior (September 3, 2025), staff were informed that while previously independent, R1 was now on 72-hour checks (as facilities protocol). Four (4) of the seven (7) staff interviewed stated they were not aware R1 required increased monitoring and two (2) of the seven (7) were unaware that the resident had returned from the hospital. The Care Plan for R1 had not been updated since April 29, 2025, the April Care Plan indicates under line item titled “Status Checks” that “Resident is okay with status checks during the day and no status checks at night”. Staff interviewed stated they were not verbally informed of increased monitoring of R1. According to electronic chart notes, R1 was checked September 4, 2025, at 8:36pm, notes indicate, “resident reports ongoing abdominal pain… reminded to use call pendant if pain increases or assistance is needed”. Electronic entry on 9/5/2025 at 3:34 AM indicates “resident is in room with no complaints of pain or discomfort during this shift”. Next electronic entry is 9/5/2025 1:59pm which indicates R1 was found at 8:15am unresponsive. Staff interviewed stated that there were issues with the call bells in a specific zone of the building and management was previously informed of this. Based on evidence received during the investigation the above allegations are SUBSTANTIATED . **An immediate Civil Penalty in the total amount of $500 has been issued for not seeking timely medical care (See LIC-421IM). An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).** Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. See LIC9099D. Appeal rights were provided. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.