Allegation: Resident did not receive timely medical attention

During the course of a self reported incident, the Department found that a resident did not receive timely medical attention.

Per Incident report dated 8/31/25 the Regional Office was notified that Alpha 1 was activated by the licensee on 8/28/25 for Resident 1 (R1), as they were sent to the Hospital on 8/28/25 due to swelling in the right side of R1’s face and “blisters burst the back of both legs”.

A Death report for R1 was sent to the Regional Office by the Licensee on 9/4/25, in which it was indicating R1 died on 9/1/25 due to a bacterial infection. Per R1’s Death Certificate for R1, it was revealed that the primary cause of death was septic shock with Stage 4 pressure ulcers. On 9/4/25, LPA Tamayo called S1 and provided additional guidance regarding completing incident reports and death reports and requested the and the LIC 602 and LIC 624 for R1. Record review indicates that Resident 1 (R1) was not on Hospice.

Hospital personnel (W1) explained that the pressure injuries could have developed over the course of a few days, but not in a single day.

CONTINUED ON 809-C2

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

This suggests that the injuries likely developed during R1’s residency at Gene-Lyn Guest Home, Inc. A review of R1’s medical records confirm the presence of multiple pressure injuries that had developed for “weeks” leading up to their death and the primary cause of death was stage 4 ulcers. It was also learned that gauze was found in R1’s wound located on the base of their spine. Hospital staff was interviewed, Witness 2 (W2) stated, “It seemed like someone was trying to clean the wound but was inexperienced”.

Daily notes dated 8/26/25 indicate that the primary care staff (S3) noticed R1’s pressure injuries prior to obtaining medical attention for R1 on 8/28/25 and S2 attempted to clean the wounds themselves prior to notifying S1 on 8/28/25. Per staff interviews and record review it was discovered that staff were aware staff should call 911 for emergent situations but did not do so. Staff were also aware they cannot retain a resident with Stage 3 or 4 Pressure Injuries.

During a facility visit on 8/21/26, LPA Tamayo provided guidance to S1 and S3 regarding the requirement for training staff to call 911 in an emergency and not delay care including not calling the administrator first. Based on information received from documentation and interviews, the following deems this allegation to be substantiated. A $500 immediate civil penalty applies.

Allegation: Resident died due to severe pressure injuries sustained while in care.

The Department conducted an investigation regarding the allegation “”Resident died due to severe pressure injuries sustained while in care”, the investigation consisted of record review and interviews.

On 8/21/25 and 9/17/25, LPA observed administrator, Grace Quirez (S2), was not present at the facility. On 8/21/25, S1 stated that they are “always” at the facility and act as the main administrator. LPA Tamayo provided S1 and S3 with guidance around needing to call 911 and/or Hospice without any delay in the case a resident is in need of medical attention. Additionally, LPA provided S1 with guidance around needing to create an updated appraisal for residents when there is a change of condition or after 12 months from the last appraisal date, which ever comes first.

CONTINUED ON 809-C3

Medical records state that R1 had a stage four Pressure Ulcer for “months” leading up to their death and the primary cause of death for R1 was septic shock with stage 4 pressure injuries. Hospital personnel, W1, explained that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gene-Lyn Guest Home, Inc.

Staff was aware staff should call 911 for emergent situations and the facility cannot retain a resident with Stage 3 or 4 Pressure Injuries. Based on information received from documentation and interviews, the following deems this allegation to be substantiated. A $500 immediate civil penalty applies. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S.

The above deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.