complaint·June 16, 2025

Staff don't meet residents' hygiene needs.- SUBSTANTIATED It was reported that a resident was found soiled from head to toe with urine and feces. LPA reviewed Resident 1’s LIC602 Physician’s Report which states that R1 is incontinent. LPA reviewed R1’s Individual Program Plan which states that R1 requires full assistance in all of their personal care and daily living needs. IPP further states that R1 is frequently incontinent. LPA reviewed the facility’s daily checklist and it is documented on 05/04/2025 6:00 PM to 4:00 AM shift under the item “Check MC MW RD & KLM When starting and leaving your shift.” A staff had initialed this as being completed (in blue ink), but there is a note written in black ink “both MC & MW were soaked x10”. LPA reviewed hourly logs for Resident 1 (R1) for the dates of 05/02/2025 through 05/05/2025. On 05/02/2025 07:40 AM R1 “showered/wet/old BM”. 05/04/2025 05:00 AM “R1 soaked”. LPA reviewed a photograph that showed R1 standing up wearing a white shirt, the shirt had urine stains that extended to R1’s chest. Staff interviewed stated they have occasionally found R1 had not been toileted when they came on shift in the morning. Administrator stated that staff had reported this incident to her and sent her photographs of the incident. This allegation is substantiated. Based on interviews, documents and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Casey Foster.