complaint·March 23, 2026

Allegation: Facility does not have sufficient staff to provide care and supervision to residents It was alleged the facility is operating without enough staff to properly care for residents in care. Five (5) of five (5) staff members interviewed agreed that the facility was understaffed and staff were unable to care for residents properly because of this. Two (2) of two (2) residents interviewed agreed that the facility had been regularly understaffed to meet their needs. One resident, R1, claimed they had waited for approximately two hours for staff assistance to use the restroom. Another resident, R2, claimed they were left unattended in the restroom for approximately 1.5 hours and had been yelling for assistance during this period. 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 are not provided with proper training to care for residents . It was alleged that staff at the facility are not being provided with required training. LPA reviewed three (3) employee files at random and found two (2) of three (3) staff reviewed had no current CPR training and one (1) of three (3) had no current First Aid training. Based on observations 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 additional LIC 9099-C Allegation: Facility is not reporting incidents to Licensing . It was alleged that the facility was not reporting serious or unusual incidents to Community Care Licensing (CCL). During a visit to the facility on October 21, 2025, LPA conducted an interview with Administrator, Bailey Malagon. It is noted that administrator had been employed by the facility for approximately three (3) weeks at the time of the visit. Administrator conducted a review of the facilities in-house incident reporting system between August 2025 and October 2025 and discovered several incidents that had not been reported to CCL including a resident death and (5) separate incidents that required the residents be transported via Emergency Medical Services. 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, Grace Hawkins. Staff does not clean biohazard. It was alleged that staff were not cleaning up soiled briefs from the floor of the facility. During an inspection of the facility, LPA did not observe any soiled briefs or other biohazard materials left on the floor around the facility. Four (4) of five (5) staff members interviewed stated this was not something they had ever observed while working at the facility. Staff stated briefs are disposed of immediately once residents were changed. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED Staff not providing residents with new chucks. It was alleged that staff were not changing out resident’s “chuck pads” once they were stained. The facility utilizes washable “chuck pads” and staff are reportedly directed to discard of “chuck pads” that are heavily stained and unsanitary. Four (4) of five (5) staff members interviewed agreed that heavily stained chuck pads are disposed of and replaced with new pads. These staff all claimed that the facility has a large quantity of extra “chucks” for resident use. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED Staff left resident in soiled briefs for a period of time . It was alleged that staff left a resident, R3, in soiled briefs for an extended period of time. It was not clear the amount of time this resident was left in soiled briefs, nor was it clear if any rashes or injuries were sustained from this alleged action. Four (4) of five (5) staff interviewed denied leaving this resident in soiled briefs for any extended period of time. These staff indicated all residents are checked every two hours or less, if needed. LPA reviewed staff care notes for this resident and found no indication of the resident sustaining any type of injury that would result from this lack of care. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED Continued on additional LIC 9099-C Staff did not provide assistance to resident in a timely manner. It was alleged that a resident (R1) had pushed their call button and waited approximately two hours for assistance from staff. LPA interviewed R1 who stated the same information. R1 stated the facility’s call buttons were inoperable and staff were unable to hear R1 calling for assistance (see substantiated complaint control #59-AS-20251016114017) R1 indicated they had needed assistance using the restroom and was left in their bed for “2-3 hours” after attempting to use the facility call system. R1 further stated “I was soaked and my bed was soaked. This is happening regularly.” R1 was unable to give an approximate day this had occurred. Five (5) of five (5) staff interviewed denied leaving R1 unattended for more than 2 hours at a time as facility protocol is to conduct checks on residents at least every two hours. LPA reviewed facility care notes which stated “This morning when care staff went in to check on resident they found that (R1) was soaked head to toe in urine due to resident completely refusing to have care done during the night because (R1) says (R1) does not want to be woken up i told (R1) that it is the law that care staff change (R1) and check (R1) every 2 hrs (R1) said well if i hit them its not (R1) problem notified rcc of (R1) behavior and faxed (R1) MD. No other concerns at this time.” LPA noted two other instances in the care note records where R1 refused changes by care staff. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED Multiple residents experiencing falls at facility while in care of staff It was alleged that several residents were experiencing falls while in the care of staff. LPA reviewed care notes and incident reports that were documented between July 1, 2025 and October 14, 2025, which indicated there were four (4) residents who had sustained five (5) falls total in this period, with one resident falling twice. According to the care notes, all the falls documented were unwitnessed and care staff called Emergency Medical Services immediately upon discovering the residents had fallen and assessing for injury. Although record review does indicate residents had experienced falls, the amount recorded during the 3-month period does not indicate an excessive or “abnormal” number of falls and all the falls were reported as unwitnessed, not while in the direct care of a staff member. LPA interviewed administrator who stated the care plans of each resident who had experienced a fall were updated as needed. 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, Grace Hawkins, via email.