complaint·November 18, 2025

...Continued from 9099 The Needs and Services Plans (NSP), reflective of the previously noted assessments, states that R1 requires “Total Assist” for Bathing, Grooming, Dressing and Ambulation. The two (2) NSPs also state that for Toileting and Transfers R1 will require a “two (2) person assist”. During review of facility staff schedules LPA observed that only one (1) Caregiver (CG) was assigned to the entire Assisted Living unit. The facility currently has a probationary license. As part of the Stipulation and Waiver, and Order dated 6/30/2022, the License understands that facility staff must be hired in numbers necessary to meet the needs of the residents. To that extent, each Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Medication Technician (MT) will not be a direct care staff but may provide support when not distributing medication. LPA reviewed facility charting notes for resident R1 from 4/4/2025 to 7/23/2025. From 4/4/2025 to 4/30/2025 there are four (4) entries. The April entries do not state that R1 is being turned or repositioned. There is one (1) charting note entry for May. The single May entry does not state that R1 is being turned or repositioned. There are twenty-one (21) charting note entries for June for the dates of 6/1/2025 to 6/25/2025. On 6/6/2025 charting notes state, “We noticed the beginning of a peel on the resident bottom. We put barrier cream. RSD has already been notified family and doctor. Please reposition (them) and continue to put barrier cream. Will continue to monitor”. Charting note entries on 6/6/2025 & 6/7/2025 note that barrier cream has been applied. Charting note entry on 6/11/2025 state, “Nurse from Advanced Home health care to assess resident for wound care on their coccyx area. Nurse stated their wound is a Stage 2. Relative/POA will be bringing extra pillows to assist with repositioning them. Care staff are to support repositioning appx every 2 hours or as needed.” Later on 6/11/2025 there are two (2) additional charting note entries that state resident was repositioned every two (2) hours. On 6/12/2025 a charting note entry states that R1 was repositioned every two (2) hours. From 6/13/2025 to 7/23/2025 there were no further charting note entries related to repositioning R1 every two (2) hours. Additionally, there is video showing R1 being moved to a wheelchair positioned at the base of the bed in front of the television at approximately 5:40 AM. Continued on 9099-C2... ...Continued from 9099-C Video shows R1 was moved back into their bed at approximately 1:32 PM. During review of facility staff schedules LPA observed that one (1) Caregiver (CG) was assigned to the entire Assisted Living unit during the thirty (30) days preceding R1’s being diagnosed as a Stage 2 wound. Based on LPA’s interviews and record review, 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, are being cited on the attached 9099D. Exit interview conducted. Copy of LIC-9099, LIC-9099C, LIC-9099C2 LIC-9099D, LIC-811 Confidential Names, Plan of Corrections and Appeal Rights discussed and provided to back up Administrator Burton. Signature on form confirms receipt of documents.