complaint·November 13, 2025

LIC9099-C (Page 2) Allegation: Staff retained resident requiring a higher level of care Finding: Unsubstantiated On 01/13/2025, Licensing Program Analyst (LPA) interviewed Witness 1 (W1), who stated that they began receiving multiple bills from ambulance services and hospital visits that they were unable to pay. W1 reported that they were not the one contacting 911 or sending Resident 1 (R1) to the emergency room (ER). W1 stated that R1 was sent to John Muir Hospital in Concord because R1 “wasn’t listening.” W1 further stated that R1 had been diagnosed with frontal lobe dementia, which required a higher level of care than what the facility could provide. W1 further stated that when R1 went to John Muir Walnut Creek he was sent back to the facility on hospice because they think the "idea to not send him back and that John Muir doesn't want to keep seeing him constantly." W1 stated that R1 was only on two types of meds and once he got on hospice, seven more types of medications were added. LPA reviewed R1’s Physician’s Reports (dated 08/14/2024 and 11/06/2024), which indicate a diagnosis of possible frontotemporal dementia , with additional notes reflecting behavioral disturbance and advanced dementia , respectively. Record review showed a change in R1’s condition, with documentation of increased confusion, disorientation, refusal or forgetfulness in following instructions, and episodes of aggressive behavior. The Pre-Admission Appraisal (dated 10/22/2024) notes “Higher level of care” for Question #1. Despite these findings, the overall Care Plan identifies R1 as mostly independent in activities of daily living. LPA reviewed that 911 was called 10/28/24 and 11/10/24 per internal incident reports. LIC9099-C Continued... LIC9099-C (Page 3) Allegation: Staff did not adequately manage resident’s behaviors Finding: Unsubstantiated On 01/13/2025, LPA interviewed W1, who reported that R1 exhibited aggressive and inappropriate verbal behaviors, including racial slurs and profanity directed at W1, their pet, and neighbors. W1 stated that R1’s behaviors were difficult to manage and that facility staff—many of whom were students—should have been better trained to address dementia related behavioral issues. W1 stated that despite these ongoing behavioral challenges, the facility repeatedly sent R1 to the emergency room instead of implementing effective behavior management interventions or arranging a more appropriate level of care. LPA reviewed the staff “2024 Annual Veteran Training Calendar.” (updated October 31, 2024). The training calendar shows courses on Resident Rights and Elder Abuse (in relation to Dementia), Dementia: Positive Approach and Dementia: Leading Causes of Expressions and How to Respond as examples. Allegation: Staff did not safeguard resident’s personal belongings Finding: Unsubstantiated During interviews, W1 stated that R1’s missing blanket was later located. There was insufficient evidence to determine that the facility failed to safeguard R1’s personal belongings. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is UNSUBSTANTIATED . No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director, Tracey Ingleman and a copy of this report was provided.