complaint·February 24, 2026

Staff left residents in soiled diapers for an extended period of time. – SUBSTANTIATED It was reported that staff leave the residents soiled diapers for hours. LPA reviewed care plans for Resident 1 (R1) and Resident 2 (R2). Both residents are incontinent and require incontinence care as needed using peri care protocol. Staff instructed to monitor urine and stool, monitor pad. Keep skin dry, keep residents clean and comfortable. The care plans include a schedule of required toileting times per day. LPA reviewed Recorded Care Reports for December 2025 and January 2025 for Resident 1 (R1) and Resident 2 (R2). The care reports show that staff did not record toileting care for ether resident during these months. All staff stated that the residents were not left in soiled diapers. It was determined since staff did not record that toileting care had or had not been completed for either resident there is no proof that the care was provided as outlined in the care plan. LPA is substantiating the allegation based on staff not being competent enough to keep accurate records on incontinent care. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins. Untrained staff administering medication to residents. – UNSUBSTANTIATED It was reported that a medication technician does not have the required training. LPA reviewed documentation of required medication technician training for Staff 2 with a final exam with a score of 100%. Interviews revealed that staff 2 completed their med tech training which included shadowing an experienced med tech. This allegation is unsubstantiated. Staff worked while under the influence of drugs impairing their ability to provide adequate care and supervision, which presents a risk to residents in care. – UNSUBSTANTIATED It was reported that a staff smokes marijuana and comes back into the facility smelling of marijuana. LPA reviewed the facility’s drug and alcohol abuse policy which states “the use of drugs or alcohol, or being under their influence, jeopardizes the welfare and safety of our residents, employees and visitors, as well as our productivity and efficiency. Your compliance with the following provisions of our workplace drug and alcohol policy is a condition of employment.” All staff interviewed stated they had no knowledge of any staff smoking marijuana while on duty in the facility and working with residents. No staff have witnessed any staff smoking marijuana. All staff stated that no residents had complained of staff smelling of marijuana. This allegation is unsubstantiated. Medication errors - UNSUBSTANTIATED It was reported that a med tech is overmedicating and under medicating a resident. LPA reviewed medication administration record (MAR) for December 2025 and January 2026 for Resident 3 (R3) which revealed that all medications were dispensed as prescribed. All staff interviewed stated they had not witnessed or heard of a med tech over or under medicating any residents. This allegation is unsubstantiated. Staff are not providing adequate food service to residents. – UNSUBSTANTIATED It was reported that the facility does not serve the residents food timely, serve them hard biscuits, and sometimes some residents don’t get any food and must wait for lunch. Staff interviews revealed that if a resident does not want to come to the dining room for meals staff bring a tray to the resident’s room. Residents always get their meals. 1 of 5 staff stated that a hard biscuit was served to the residents one time. This allegation is unsubstantiated. Staff are not responding to residents call buttons. – UNSUBSTANTIATED It was reported that staff don’t respond to the residents’ call buttons because they’re busy sitting around smoking on breaks all day. During a visit to the facility on 01/06/2026 LPA observed staff answering call lights timely. Staff who were interviewed stated they had not seen staff ignoring calls lights. One staff stated they had witnessed other staff sitting on their phones and asked them not to. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins.