complaint·October 21, 2025

Allegation: Staff did not prevent residents’ room from being unsanitary. It was alleged that staff did not prevent a resident's room from being unsanitary. On April 18, 2025, LPA received photographs of an unspecified resident’s room with what appeared to be feces on the bed and several surfaces. It was alleged that night staff would leave the mess for the following shift to take care of. The Facility Administrator admitted that a resident had been exhibiting this type of behavior. LPA observed the care notes and doctor’s notes for this resident and observed documentation of the facility reaching out to the primary care physician to report the behavior and to have the resident seen by the doctor for a change in condition. LPA interviewed 4 staff, of which, all noted they knew about the residents’ behaviors; however, all staff stated the mess was cleaned up as soon as it was discovered. One staff member stated the resident’s family had cleaned up the mess before during a visit as they were the first ones to observe the resident after it had occurred. However, on April 18, 2025, April 22, 2025, and May 27, 2025, during visits to the facility, LPA observed the same resident’s room to smell strongly of urine. The resident’s bedding was saturated with urine and thus unsanitary. During each of these visits, the scent of urine was strong enough to be detected from the hallway outside of the room. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Bailey Malagon, Administrator.