complaint·January 27, 2026

Allegation: Staff did not seek medical attention in a timely manner. It was alleged that a resident had experienced two falls on the same day and staff members failed to seek medical attention for that individual. The complainant in this matter was unsure of the name of the resident, the number of the resident’s apartment at the facility, or the exact date of when the falls occurred. A physical description of the resident was provided; however, the resident was unable to be positively identified. No staff interviewed were able to determine which resident this allegation may have been referring to. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Allegation: Residents do not have access to personal hygiene items It was alleged that there was a significant shortage in personal hygiene items at the facility including, but not limited to, toothbrushes, lotion, hairbrushes , briefs, and personal wipes. During a facility inspection on June 18, 2025, LPA and Administrator conducted a tour of the facility. LPA observed a large closet full of excess wipes, briefs, and basic toiletries available for residents. Additionally, LPA observed residents’ personal toiletries that were kept in individual caddies for staff to use while assisting residents. Six (6) of six (6) staff interviewed stated they have never observed any resident to go without briefs, wipes or basic toiletries. Staff stated that most resident's families provide any supplies they may need for the month and it is recorded on a log in the facility lobby. Any resident who's supplies were running low, staff notified the families. LPA observed a supply order list for the previous three months that contained toiletry items, multiple packages of briefs, anad multiple packages of wipes. LPA observed a "supply drop - off list" dated for the previous three months that had dozens of entries from family members dropping off supplies. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Allegation: Facility not meeting incontinence needs of residents in care It was alleged that staff were not meeting the incontinence needs of residents in care by not supplying residents with depends/briefs when necessary and leaving residents in soiled briefs for an extended period. During the course of the investigation, LPA conducted several tours of the facility and observed a strong smell of urine in specific wings of the facility where it was known that resident's with incontinence issues were living. LPA attempted to interview residents who were on an incontinence plan, however, LPA was unsuccessful due to each resident’s dementia diagnosis. On October 25, 2025 LPA was able to interview one (1) resident who indicated there have been several instances where they felt they were “forgotten” about by staff while residing at the facility. The resident indicated that the facility is regularly short staffed and there may have only been one (1) or two (2) staff members available to assist the entire facility. The resident admitted there had been times when they needed to use the restroom and were unable to get out of their bed on their own because staff never responded to their calls or assistance. LPA interviewed several staff members during the course of the investigation. Four (4) of six (6) staff stated that they had observed residents being left in soiled briefs for an unknown extended period of time, particularly at shift changes. Staff stated that on more than one occasion, they would arrive for their shifts and find residents soaked through briefs, "chuck" pads, and down to their mattress while being asleep. Two (2) staff stated that it was facility policy to check residents hourly and it was unreasonable to believe that a resident could soak through their belongings that quickly, indicating staff were not properly meeting the incontinence needs of the residents. 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 Administrator, Bailey Malagon.