complaint·April 21, 2026

Pg 2 On the allegation of staff physically abused resident resulting in bruises LPA’s conducted interviews with residents, staff, witnesses, and obtained photos. On 3/21/2025 LPA’s interviewed R2 Who stated that sometimes when staff bathe them, they are too rough. LPA‘s interviewed W6 who states that they noticed bruising on R2 when they came to visit them. W6 states that when they asked R2 what happened they stated that W3 had left the bruises because they were being too rough while bathing them. W6 states that they were informed the bruises were a result of W3 grabbing R2 too tightly. W6 states that a police report was not made because W3 had already been fired. LPA‘s obtained photographs that showed R2 had sustained bruising on both forearms. LPAs observed that the bruising is consistent with being grabbed, therefore, the allegation of staff physically abused resident resulting in bruises is substantiated. On the allegation of staff financially abused resident the department conducted interviews, obtained documentation, and conducted a financial audit. During the investigation LPA’s interviewed R4 who stated that in late 2024 they were being financially abused. LPA’s interviewed S2 through S12. S1, S2, S11, and W1 stated that they had all heard of a resident having been financially abused by the previous Resident Liaison (W2) however they were not sure if it was true. LPA interviewed the previous executive director who stated that they had reported possible financial abuse to the San Leandro police department, but nothing further came of the investigation. LPA‘s requested potential documentation of financial abuse on 3/21/2025 . Previous Executive Director stated that they did not have record of any proof of financial abuse. On 6/12/2025 LPA’s return to the facility and again requested documentation of financial abuse and the executive Director was able to produce a document stating the name of employee of former resident liaison (W2) on an official bank document for R4. LPA’s then requested a financial audit of R4’s bank accounts on 8/06/2025. The financial audit revealed that W2 had been getting direct transfers from R4’s bank account to their personal account. Therefore, the allegation of staff financially abused resident is substantiated. Report Continues on LIC9099-C Pg 3 On the allegation residents rooms are malodorous LPA’s toured the facility on 3/21/2025. While touring the facility on 3/21/2025, LPA’s observed on the second floor a strong smell of human urine. LPA’s briefly spoke to a staff member passing by name unknown, who stated that urine is a common odor in that part of the facility. LPA’s were able to locate the odor in R17’s room. LPA observed that R17 utilizes a catheter and that urine was spilling onto the floor. LPA’s interviewed R17 who states that staff do not come to assist in cleaning the urine and that they are charged extra if they need their floors cleaned. During the course of the investigation LPAs also conducted interviews with S1 and S6. S1 states that staff should be cleaning the floors and also S1 stated that rooms are cleaned on an annual schedule however if a resident has an accident on the floor that they need to come down to the front desk to ask for their room to be cleaned. S6 states that they have noticed lingering urine odors before. Therefore, the allegation of resident's rooms are Malodorous is substantiated On the allegation, staff did not ensure food is properly disposed LPA’s toured the facility and made observations. On 8/21/2025 LPA’s observed in R4’s room food with mold and expired in their refrigerator. The food observed was covered in saran wrap, and in dishes provided during tray service. At the time of the Observation, LPA’s observed R4 was bed bound and on full care. LPA‘s interview S1 who stated that R4 was currently receiving tray service and incontinence care. LPAs found through interviews that staff are expected to deliver the trays and then return a few hours later to retrieve the dishes and trays after meal times. LPAs also interviewed S2 and S10 who stated that they have noticed staff not removing trays as required and food leftovers not being disposed of properly. Therefore, the allegation of staff did not ensure food is properly disposed is substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. On the allegation of “Questionable Death” the Department obtained copies of the death report for R1. After a review it was found that R1 passed away from ventricular arrhythmia and coronary artery disease. LPA’s also reviewed R1’s medical records and physicians reports and observed that R1 had related pre-existing conditions. Therefore the allegation of Questionable Death is unsubstantiated On the allegation of “Staff do not ensure residents showering needs are being met” LPAs interviewed R2, R3, R4, R7, and R8 . R2 and R7 both stated that their showering needs are being met. LPAs also reviewed shower logs and care plans. LPAs observed that showers are being provided and care plans are being followed in regards to showering needs therefore the allegation Staff do not ensure resident's showering needs are being met is unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.