Complaint·April 9, 2025

Allegation: Staff served poor quality food to residents Finding: Substantiated LPA interviewed W1 that stated the food at the facility is not nutritious. W1 stated that lunch, dinner is cold food. On 03/13/2025, LPA interviewed R1, R2, R3, R4, R5, R6, R7, R8 and R9. R1-R9 all stated that the food served is ok, sometimes it's cold. R1-R9 stated that they have not seen a menu and that they don't have choices. LPA observed the meals for lunch/dinner on 03/13/2025 and 04/09/2025. Meals observed was a sandwich on wheat bread, lasagna, mixed veggies with a slice of wheat bread. Allegation: Staff was unable to communicate due to language barrier Finding: Substantiated LPA interviewed W1 that stated one of the caregivers, S2, does not speak English and when R1 needed a bed bath, S1 used his phone to translate through Google. On 03/13/2025, LPA interviewed S1 that stated S2 does not know English and is currently taking classes to learn English. LPA interviewed R1 that stated it is frustrating sometimes to keep asking or telling a caregiver something with your care need and they don’t understand. R1 stated that it would be good if the caregivers utilized a translator app to communicate. LIC9099-C Continued... LIC9099-C Continued... Allegation: Staff did not provide resident’s records to resident’s authorized representative Finding: Unsubstantiated On 12/16/2024, LPA interviewed witness (W). W1 stated that they requested some information regarding Suncrest Hospice and was denied the file by one of the Med Techs Staff (S). W1 stated that they are the responsible party of resident (R) R1. On 03/13/2025, LPA interviewed staff (S). S1 stated that W1 asked for the shower schedule which included other resident’s names and that is why S2 denied the file to W1. S1 further stated that W1 always had R1’s hospice file. On 04/09/2025, LPA interviewed S2 that stated the particular file requested was a file that consisted of other residents' care notes and shower schedules written by caregiver staff. S2 stated that they told R1's authorized rep that they couldn't give them the file because the file had other resident's information which is confidential. Allegation: Staff did not ensure resident's room was cleaned and sanitized Finding: Unsubstantiated LPA interviewed W1 that stated they were told by the hospice aide that the bathroom was filthy and smelled of urine. W1 stated that there are four (4) residents that share bathroom and W1 has observed urine and poop on the floor. LIC9099-C Continued... On 03/13/2025, LPA observed the shared bathroom. The bathroom toilet and floor appeared clean. On 04/09/2025, LPA interviewed R2 that stated housekeeping cleans the shared bath room 2 times a week. LPA interviewed S1 that stated housekeeping cleans the bathroom 4-5 times a week. If there is an accident and housekeeping isn’t available, the caregivers will clean the bathrooms. 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 are UNSUBSTANTIATED . Exit interview conducted and a copy of report was given . LIC9099-C Continued... Allegation: Staff did not respond to resident's requests for assistance in a timely manner Finding: Substantiated On 03/05/2025, LPA interviewed fifteen (15) residents (R). R2, R3, R4, R6, R7, R8, R9, R13, R14 all stated that when they use their call button for assistance with care, it will take from 20 to 30 mins before someone comes to their room to respond. R2, R3, R4, R6, R7, R8, R9, R13, R14 stated that the caregiver comes to the room, turns the light off and then never returns. R7 most of the time it is during the night shift that doesn’t show up to work and weekends. R5 stated that once they had to wait for the following day before someone would come help them. R5, R10, R12 and R15 stated that they have no use for the call button. R5 stated that they heard their neighbor yelling out to the staff for help and said, “I pressed my call button but how come no one here to help me”. R5 further stated that the staff came to their neighbor’s room and just said I will come back but never did. On 03/05/2025, LPA tested the call button while waiting for a response in a resident’s room. The time of the test was around 1:00 pm and it took approximately 16mins before a caregiver responded. 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. A copy of this report and appeal rights provided