complaint·February 11, 2026

Continued from LIC9099 Investigation Findings: It was reported to the department that there was no toilet paper or paper towels in any of the residents’ bathrooms, and residents were using writing paper and newspapers as toilet paper. S2 reported that staff are instructed to put out only one roll of toilet paper per day. S2 has seen magazine and newspaper in toilets while cleaning, as did other staff members. LPAs observed only one roll of toilet paper in each bathroom and no paper towels in any bathroom. S3 informed LPAs that staff limit the amount of toilet paper and paper towels in each bathroom to prevent colgs as residents have been clogging toilets. Based on observation and interviews, the allegation is SUBSTANTIATED. Allegations: Facility is not meeting the resident’s incontinent care needs Investigation Findings: It was reported to the department that staff are not changing a resident with incontinence frequently. LPAs interviewed R1, who was not alert nor oriented enough to provide adequate information. The facility has a changing chart near the bed. Upon review, LPAs observed gaps between changing as long as 14 hours, and there is no log of staff checking R1’s diaper. Based on observation and record review, the allegation is SUBSTANTIATED. Allegations: Licensee does not ensure staff are present at all times Investigation Findings: It was reported to the department that the facility has no staff coverage on Monday through Sunday from 2:00 AM to 7:00 AM. LPAs reviewed the facility’s LIC 500 and confirmed there is no staff scheduled 2:00 Am to 7:00 AM Monday through Sunday, therefore this allegation is SUBSTANTIATED. Allegations: Staff do not ensure that residents have adequate hygiene supplies Continued on LIC9099-C Continued from LIC9099 Investigation Findings: it was reported to the department that there is a lack of basic necessities, such as soap and shampoo in the facility. LPAs observed one bottle of shampoo and 1 bar of soap in a supply cabinet, but none in any bathroom. The facility’s Admission Agreement specifies that basic needs, including soap and shampoo, are included in the rent. S2 informed LPAs that some residents will buy their own products based on personal preference, however the facility does not have an adequate supply to cover residents that do not buy their own or run out. Based on observation, the allegation is SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of corrections by plan of correction due date and any repeat violation within 12 month period may result an additional civil penalty. An Immediate and repeat Civil penalty of $1000.00 is assessed. Deficiencies, plan and proof of corrections were discussed with Administrator Ferdinand Gutierrez Exit interview conducted, Appeal Rights, and copy this report provided. Continued from LIC9099 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. No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.