Complaint·February 12, 2026

Continued from LIC9099... LPA conducted confidential interviews with Licensee and facility staff (S1, S2 & S3) revealed conflicting information regarding the timeline and services provided to R1. LPA conducted interviews with residents (R2, R3 & R4) confirmed that staff check them regularly during night shift. According to interviews conducted by LPA with S3, R1 and all other residents were checked hourly. Per S3, the night before R1’s hospitalization, R1 was described as not engaged like R1 used to make gestures to respond to questions, but when they performed their last check at 5am, R1 was observed sleeping, breathing without any signs of distress. Investigation revealed that facility morning staff (S1 & S2) found R1 at around 7:30am when they performed their usual rounds to check on residents, R1 was observed with a significant change of condition, which prompted S1 to call the Licensee immediately. According to interviews conducted with the Licensee, the facility staff informed them about the significant change in condition of R1. Although R1 was observed with signs of distress at about 7:30am, LPA obtained Santa Rosa Fire Department records revealed that they were not contacted until they received emergency call on 10/27/25 at 11:08:54am to transport R1 to the hospital. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued. The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f). Continued from LIC9099A... However, medical records revealed that R1 was bed-bound and receiving home health services for wound care since September 2, 2025. Although R1 clearly had a change of condition and ambulatory status requiring frequent reposition, the facility did not obtain an updated physician report and care plan. Furthermore, R1’s medical records revealed that on 9/10/25, R1 was transported to the emergency room with acute severe ankle problem due to a fall while they were getting out of the bath and fell twisting the left ankle, it was unclear in the after visit summary if R1’s was still ambulatory or not, but LPA reviewed incident report logs for this facility and the fall nor the hospitalization was not reported to the Department as stated in regulations. On 12/18/25 at approximate 8:56am, Licensee contacted LPA to notify the Department that R1 passed away while in the hospital after two days hospitalized due to a massive stroke. LPA inquired about reporting requirement, but Licensee stated that they have mailed the required death report, but LPA did not receive it until 1/2/26. LPA will address both deficiencies in case management. According to R1’s medical records, R1 was receiving home health services for wound care on 9/2/25, 9/4/25, 9/8/25, 9/11/25, 9/15/25, 9/18/25, 9/22/25, 9/25/25, 9/29/25, 10/2/25, 10/6/25, 10/9/25, 10/13/25, 10/16/25, 10/21/25, 10/22/25 and 10/24/25. Based on interviews conducted with Licensee confirmed that home health has been providing wound care services to R1 for the past couple of months and a nurse had been coming out normally it was once or twice a month, then visits were increased to twice a week, when skin deterioration and wounds were not getting better. Per Licensee, R1’s wounds were never staged because it started a little reddish, then it will heal, until it got to a point where they were not healing and last Friday (10/24/25), home health notified them that a wound specialist was scheduled to come on Monday (10/27/25), but R1 was not seen due to hospitalization. LPA conducted interviews with third party agency individual (I1) who confirmed that they were providing wound care services to R1 on average twice per week, the facility reported to them about R1’s pressure injuries were developing very rapidly. Per I1, R1’s wounds for one week were manageable, but the following week their wounds were significantly bad, and they were not getting better, but there were no concerns raised regarding the care or staff training that the facility provided for R1. Based on the information obtained by the Department during this investigation, the facility assisted R1 with care and reported changes of condition to the assisting agency. A finding that the allegation of lack of care from staff resulted in resident sustaining pressure wounds while in care is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.