complaint·November 24, 2025

Continued from LIC9099. During the investigation the complainant stated R1 was charged additionally for basic services and therapy. LPA reviewed the admission agreement and observed the additional services in section F (Level of Care) which were also included in section B (Basic Services), except for therapy. S3 stated R1 did receive therapy from home health as well as the staff. Based on LPA’s interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of the appeal rights and this report provided. Continued from LIC9099. During the investigation the complainant stated R1 requested information regarding medication and R1’s financial contract to be made available to his family members and staff were not allowing an authorized representative to access R1’s records. During interview with W1, it was stated that the facility gave all information requested. LPA reviewed the durable power of attorney notarized January 26, 2023, and the advanced health care directive notarized on November 21, 2024. Both named R1’s responsible person that was able to make decisions. Allegation: Staff are unable to communicate effectively During the review of complaint submitted the complainant stated R1 reported that the staff often spoke limited English or was hard to understand which made staff unable to communicate effectively mostly at night. W1 stated during investigation there was not any problem communicating with the staff. LPA spoke with staff at the facility and did not have any problem communicating. Allegation: Staff demonstrated inappropriate form of discipline towards a resident During the review of complaint submitted the complainant stated R1 reported being punished/neglected for asking for help at night, which demonstrated staff conducting inappropriate form of discipline towards a resident. The complaint stated R1 received mental abuse. W1 stated during interview that R1 was never disciplined or Continued on LIC9099C. Continued from LIC9099C. neglected. W1 stated the facility took care of R1 to the best of their disability. S3 stated there was no report of any type of punishment or discipline towards any of the residents. Allegation: Staff did not answer timely to the facility telephone During the review of complaint submitted the complainant stated the facility staff never answered the facility telephone and the voicemail box was always full. LPA reviewed text messages dated December 20, 2024, between the reporting party and S3 regarding R1’s phone and the facility phone. S3 stated that the staff answers the phone but there were times when the staff is busy and not able to answer or assist R1 with his phone. S3 also stated R1’s family members called and visited the facility and there weren’t any problems. Allegation: Staff mishandled a resident's medication During review of the complaint submitted the complainant stated staff continued to administer medication and the medication was increased over the five (5) month period that R1 resided at the facility. Complainant also stated there were no visits to the doctor to justify the increase. LPA reviewed the facility assessment notes, the physician’s orders, and the medication administration (MAR) records from October 2024 until March 2025. LPA observed on the MAR’s and physician reports there were notes where the medicine was changed and discontinued. LPA observed from the assessment notes indicating there were visits and a meeting from the EASE Care nurse Continued on LIC9099C. Continued from LIC9099. for R1. S3 stated there were never any changes without the responsible party being aware. Allegation: Staff interfered with a resident's medical decisions During review of the complaint submitted the complainant stated R1 verbally expressed he did not want additional medication, but staff continued to administer the medication. LPA reviewed R1’s Advance Health Care Directive notarized November 21, 2024, which named the person responsible for R1’s medical decisions. S3 stated there were not any changes done unless the nurse makes the request and it had to be ordered by the physician. The facility staff cannot increase, decrease, or add any type of medication whether a prescription is needed or if it’s over the counter to any of the residents. Allegation: Staff did not abide to the admission agreement During review of the complaint submitted the complainant stated the facility did not abide by the admission agreement. During interviews with S1, S2, S3, and W1 it was stated that the facility did abide to the admission agreement. After reviewing the admission agreement, it was identified that the facility did abide by the admission agreement. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given .