complaint·January 27, 2026

Staff did not wear gloves when changing residents’ diapers It was alleged that the facility had run out of gloves and staff were being directed to simply wash their hands between assisting residents with brief changes. LPA interviewed six (6) current and former staff members and no staff had any knowledge of a time when the facility was out of gloves, nor had they ever been directed to not use gloves when changing residents briefs. Two (2) staff mentioned that gloves were being kept in the med room at the facility and new staff may have not know the location of supplies LPA observed a supply order list for the previous three months that showed boxes of gloves being ordered in all sizes for the facility. During an inspection of the facility on July 25, 2025, LPA observed multiple boxes of gloves in the facility for staff use. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator, Bailey Malagon. Allegation: Staff did not ensure resident was properly positioned in shower chair, resulting in a fall. It was alleged that during a PM shift on July 13, 2025, a resident (R1) had sustained a fall during a shower while being assisted by three staff members. The resident was not supposed to receive "regular" showers and was instead provided "bed baths" due to R1's bedridden status. Staff reported that the management on shift "insisted" on giving R1 the shower and did not place the resident in the shower chair properly, resulting in R1 falling to the floor and sustaining a cut to their forearm. Staff were interviewed who confirmed the allegation. LPA reviewed R1's care plan dated July 8, 2025, which stated "Bathing - Two Person Assistance- Bed bath, full assistance needed with bed bath as individual is unable to tolerate showering." LPA observed R1's Care Notes dated July 14, 2025, stating "When assisting care staff with transfer, I (staff) noticed a cut on resident's left arm that is about 1 1/2 long. I asked care staff if she knew what happened to resident she said that she had a fall last night (7/13)." 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. Allegation: Staff did not seek medical attention for resident . It was alleged that following R1's fall while in the shower, that staff failed to seek medical attention for the resident. LPA interviewed staff who confirmed this allegation. LPA reviewed R1's care notes which indicated no medical attention was sought for R1. Staff that originally attempted to report R1's fall indicated in the Care Notes that they cleaned and bandaged the cut on R1's arm and there were no further concerns. A follow-up comment from managerial staff indicated "Resident did not have a fall on 7/13, please ensure we are documenting correctly and accurately." LPA reviewed all Special Incident Reports submitted by the facility and there were none mentioning R1 sustaining a fall or that any medical attention had been sought for the resident on this date. 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. Continued on LIC 9099-C Allegation: Staff did not report incident involving r eside n t It was alleged that staff failed to report the previously mentioned incident to Community Care Licensing (CCL) . LPA conducted a review of Special Incident Reports submitted to CCL at the time the incident occurred and found no evidence of the facility reporting the circumstances as required. On October 21, 2025, LPA interviewed Administrator Bailey Malagon who conducted a search of the facilities records and confirmed there were incident reports prepared by staff reporting the previously mentioned incident. Administrator noted there was a Care Note describing the incident and R1's injury, however, a separate staff member provided a follow-up care note denying the allegations ever occurred. 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.