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32 | Emerald Valley staff first noticed redness on R1 bottom on 11/26/2023. Home health was requested on 11/28/2023 and a follow up was requested again on 12/7/2023, but services did not begin until 12/15/2023 after F1/Power of Attorney (POA) called R1’s doctor for a referral. Home health nurses visited R1 on 12/15/2023 and instructed staff to reposition R1 every two hours, and to change the dressing when it became soiled. Home health physical therapist found R1 sitting in R1 wheelchair, on R1 pressure injury, and reminded staff not to let R1 sit on R1 injury. R1 was admitted into the hospital on 12/20/2023 for low blood pressure, sacral pressure injury and blood in R1 urine. A hospital nurse (name unknown) staged R1 pressure injury as a stage 3, which was estimated to have been present for the past three weeks. R1 required debridement surgery and was discharged from the hospital back to Emerald Valley with hospice services. R1 was interviewed and said staff put R1 in R1 chair and R1 sat there all day. Staff always told R1, “We’ll get back to you,” when R1 requested help from them. R1, F1 and F2, frequently pressed R1 call button to request staff assistance but were rarely helped. Staff always said they were busy or made excuses. Emerald Valley caregivers were interviewed and admitted they found R1 lying in soiled diapers and soiled bedding on multiple occasions. NOC shift caregivers endorsed to AM and PM shifts to not put R1s water bottle on R1 bed as it often leaked and got R1 clothes and sheets wet. Because they could not transfer R1, they left R1 in wet clothes and bedding until the AM shift could change R1. Med techs were also interviewed and stated caregivers put off repositioning R1 because “R1 was too heavy.” Caregiver told me one of the other caregivers they need to constantly ask staff to reposition R1. Since staff rarely responded to their requests for help, F1 and F2 repositioned R1 themselves when they visited R1. Based on the information obtained, the findings are substantiated.
Continues on LIC9099-C2
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32 | Allegation: Staff did not ensure resident's wound care needs were met- Substantiated
It was alleged that staff did not ensure the resident’s wound care needs were met. On 1/16/2024, LPA reviewed caregivers' notes dated 11/28/2023, which noted that while S7 was conducting a round check, S7 noticed R1’s water bottle behind R1’s bed had fallen over, and water leaked on R1’s bed. S7 cannot transfer R1 and S7 left R1 in the wet bed. R1 was not changed until the following morning. On 1/25/2024, LPA interviewed S7 via phone. S7 admitted that S7 left R1 knowing that R1's wound cannot be wet for a long period of time. On 11/28/2023, S2 noted R1 had redness on the peri-area and an open area on the top of R1 buttocks. On 12/20/2023, S8 noted that R1 bottom got infected, and S8 sent R1 to the hospital due to low blood pressure and an infected bed sore on R1 bottom. LPA attempted to contact S8 multiple times but was not able to get any new information. On 12/20/2023, R1 was sent out to the hospital for low blood pressure and an infected bed sore. R1 was admitted into hospice care on 12/22/2023. S3 instructed S1 and S13 that R1 will need to be transferred back to bed after breakfast and remain in R1's bed throughout the day and needed to be repositioned every two hours on each shift. S3 instructed S1 and S13 based on R1’s after-visit summary dated 12/22/2023 and hospice care plan. However, when asked, S3 was unsure if R1 was being rotated every two hours as instructed, due to a stage 3 pressure ulcer on R1's upper buttocks.
Based on record reviews and interviews, the allegation above is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
- An immediate civil penalty of $500 is being assessed on today’s date. Civil penalty determination related to serious bodily injury is pending. LIC 421 IM is being issue today.
Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D.
Exit interview conducted with Administrator, Marissa Espinoza a copy of this report and appeal right was provided.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/10/2025
Section Cited
HSC
1569.269(a)(6) | 1
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7 | 1569.269
Enumerated rights; severability
(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by: | 1
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7 | Conduct an inhouse training to all care staff regrading skin care procedure, and Administrator agrees to review regulation with staff and submit self-certification letter to CCLD by POC date.
An immediate civil penalty of $500 is being assessed on today’s date. |
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14 | Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above by resident sustained pressure injury while in care. And Staff did not ensure resident's wound care needs were met. | 8
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Type B
06/13/2025
Section Cited
CCR
87625(b)(3) | 1
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7 |
87625 Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
This requirement is not met as evidenced by: | 1
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7 | Conduct an inhouse training to all care staff and Med Tech on ADL procedure, and Administrator agrees to review regulation with staff and submit self-certification letter to CCLD by POC date. |
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14 | Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above by Staff did not meet resident's diapering needs. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
06/13/2025
Section Cited
CCR
87465(c)(2) | 1
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7 | 87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by: | 1
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7 | Conduct an inhouse training to all Med Tech regrading med pass, medication documentation, and care procedures. Administrator agrees to review regulation with staff and submit self-certification letter to CCLD by POC date. |
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14 | Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above by Staff did not ensure proper medication assistance was provided to resident in care. | 8
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Type B
06/13/2025
Section Cited
CCR
87411(a) | 1
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7 | 87411 Personnel Requirements – General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidenced by:
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7 | Conduct an inhouse training to Director of health Services and Director of Connection for Living on facility procedures daily review on pendent report and response to call time. Administrator agrees to review regulation with staff and submit self-certification letter to CCLD by POC date. |
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14 | Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above by Staff did not attend to resident's call button. | 8
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