It is alleged that Resident #1 (R1) developed a pressure injury due to staff negligence. It was reported that R1 has contracted pressure ulcers and has been scratching the tailbone. No further information is available or provided.

Resident #1 (R1) was admitted to Carson Senior Assisted Living on February 17, 2020, according to the Identification and Emergency Information (LIC 601, dated 02/17/25). On July 11, 2025, (R1) was hospitalized at Harbor UCLA Medical Center for septic shock. During the medical assessment, it was discovered that (R1) had a left trochanteric pressure ulcer, classified as Stage II, which had deteriorated, increasing in size and depth. Additionally, there was a left ischial ulcer that remained unchanged at the time, along with a deep tissue pressure injury (DTPI) to the sacrococcygeal area that also deteriorated, presenting a non-blanching wound bed and a boggy texture upon touch.

On October 6, 2025, between 11:16 AM and 12:14 PM, the Department interviewed staff members identified as Staff # 1 through Staff #5 (S1-S5). One (1) out of the five (5) staff members was able to verify by observation that (R1) had some skin blister and that staff were applying ointment on the blister for any skin condition. Four out of the five (5) claimed to have never observed any pressure injuries on (R1). All five staff members unanimously confirmed that (R1) was hospitalized on July 11, 2025, due to a significant decline in health, and importantly, were not receiving any home health or hospice care at that time.

On September 18, 2025, at 10:19 AM, the Department interview witness identified as Witness #1 (W1). (W1) was informed that (R1) was taken to Harbor UCLA for low blood pressure, dehydration, and bed sores. Later, (R1) was transferred to Kaiser Permanente and passed away on July 20, 2025. (W1) noted that (R1) did not receive home health or hospice care while at the facility.

(Evaluation Report continues LIC 9099-C)

The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), which indicated a history of skin conditions and breakdowns. The facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. By 07/11/25, (R1) was again noted to have skin breakdown.

Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, with (10) of those having side effects that could lead to skin rashes, itchy blisters, skin reactions, or peeling, which may potentially result in pressure injuries (ref: National Institutes of Health).

Medical records from Harbor UCLA Medical Center indicate that (R1) developed three pressure injuries while under the care and supervision of the facility. The details of the injuries are as follows:

• - Wound #1: Sacrococcygeal area (Deep Tissue Pressure Injury), measuring 13 cm x 8 cm.
• - Wound #2: Left ischium (Unstageable), measuring 6 cm x 3.5 cm.
• - Wound #3: Left trochanter (Stage 2), measuring 3.5 cm x 2 cm.

Allegation #3: Staff did not seek timely medical attention for resident in care.

It is alleged that the staff failed to seek timely medical attention for Resident #1 (R1). Reports indicate that the facility neglected (R1), who was taken to the Harbor UCLA Medical Center emergency department due to concerns about low blood pressure and poor food intake. Upon assessment, (R1) was found to have low sodium levels, dehydration, and a pressure ulcer above the tailbone. It was reported that (R1) had been eating adequately in March 2025, and that the staff had not been notified about the bedsores. No further information is available or provided.

(Evaluation Report continues LIC 9099-C)

(R1) was later transferred to Kaiser Permanente and passed away at the hospital on July 20, 2025. According to facility staff, (1) out of (5) staff members observed that (R1) had a skin blister and that staff were applying ointment to address the condition. However, (4) out of (5) staff members reported never having observed any pressure injuries on (R1) and (2) out of the (5) staff members recognized a change in mental and physical change in condition.

Nevertheless, the facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. By 07/11/25, R1 was again noted to have skin breakdown. The charting notes indicate that Resident 1 (R1) is exhibiting signs of weakness and requires assistance during mealtimes. Additionally, (R1) had been showing a noticeable decline in appetite, often refusing to eat or showing little interest in food.

The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025.

The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), which indicated a history of skin conditions and breakdowns. The facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. By 07/11/25, R1 was again noted to have skin breakdown.

Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, with (10) of those having side effects that could lead to skin rashes, itchy blisters, skin reactions, or peeling, which may potentially result in pressure injuries (ref: National Institutes of Health).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099 D).

An exit interview was conducted with Jessica Ponce , and copies of the report and appeal rights were provided.

*Immediate Civil Penalty issued*

ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000)