complaint·October 30, 2025

LPAs observed that there is adequate food and snacks of good quality available to residents. LPAs also observed that at the time of the visit residents where served lunch at approximately 11:30am that consisted of homemade ground beef stew that included ground beef, tomato paste, peas, potatoes, and onions. LPAs also observed that residents with a puree diet were served a puree of bread, rice, ground beef, tomato paste, peas, potatoes, and onions. Therefore the allegation Staff are not providing adequate food service to resident's is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . exit interview conducted and a copy of this report provided. LPAs observed that on 10/30/2025 at around 3:30AM R2 was wandering the facility nude from the waist down and R3 was also wandering the facility at the same time. No staff responded to R2 or R3. LPA's also interviewed Administrator and S1 and found that there is not a set schedule for Staff and Staff checks of residents primarily in the evening. LPAs observed in R2 and R3's files that they both have documented wandering behavior. LPA's also found through interview and review of camera footage that residents requiring incontinence care are having as much as a 12 hour gap between having their incontinence changed (6pm-6am). Therefore the allegation of Staff are not meeting residents needs is Substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.