Incident investigation·August 28, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding a self reported Report of Suspected Elder Abuse SOC341 received. LPA met with Executive Director Christian Castillo at 09:45 AM and explained the reason for the inspection. On 08/21/2025, Community Care Licensing (CCL) received a self reported Report of Suspected Elder Abuse SOC341 regarding Resident 1 (R1) and Staff 1 (S1). It was reported that S1 did not report or advocated for R1 to be seen in a timely manner after observing and noting resident had a wound that was infected on 08/10/2025. On 08/22/2025, LPA Cortez spoke with the ED telephonically. ED stated that R1 had a little abrasion on their leg and it was reported on 8/10 by S1, S1 reported it had a foul smell. S1 is a nurse, and knows that when you have a foul smell it could be an infection or something. S1 called home health to set up someone who could go out and look to determine if it was a wound and was told it would take 14 days to get the process. On 8/20 a MT was frustrated and asked the Director of Nursing (DON) what was going on with R1. The DON saw R1 and said there was a foul smell and sent R1 to urgent care, where they were told they needed to be taken to the hospital. During today's visit the LPA interviewed the ED, briefly spoke to the DON, and conducted a file review. The ED revealed that they were informed by the doctor at the hospital that R1's abrasion was not a pressure injury, however R1 was getting Home Health to treat their abrasion on their leg and O2. File review revealed that R1 was at the hospital from 08/22/25 to 08/26/25, and reason for their visit was listed as cellulitis. Wound infection was also listed as a medical problem. Report will continue on LIC809-C, 2nd page. A review of R1's charting notes revealed that on 08/10/25, a caregiver reported that the resident's wound on their left shin "seemed infected." The resident's skin was examined. The skin was broken about an inch and a half in diameter and foul odor was noted. Even though, staff were treating the wound with normal saline and patted dry, R1 was not seen by a medical provider until 08/22/25, leaving them with an infected wound for over ten (10) days. The following deficiency was cited from the California Code of Regulations, Title 22 and California Health and Safety Code. (See LIC 809-D) Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.