complaint·November 5, 2025

Pg. 2 continued On the allegation "Staff not following residents care plan" the following was found: On 7/16/2025 LPAs A Gomez and T Syess-Gibson conducted the initial investigation visit. During the visit LPAs met with staff 1 (S1), Licensee, resident 3 (R3), and resident 4 (R4). LPAs reviewed available records for R1, R2, R3, and R4. LPAs observed in R3's records that they required assistance rotating every 2 hours. LPAs were at the facility continuously from 1:00PM- 4:15PM and observed that R3 was not rotated until LPAs requested that staff rotate them. On 8/20/2025 LPAs A Gomez and Y Brown returned to the facility to continue the investigation. LPAs observed that the Facility was crushing medications for R3 and R4 without a crush order on file. On 11/4/2025 LPA A Gomez interviewed R1, R2, and witness 1 (W1) . During the interviews with W1 it was disclosed that R1 sustained pressure injuries due to facility staff not encouraging and assisting R1 as discussed as part of their care plan. It was also disclosed that R1 was having flare-ups with their skin due to inconsistent use of their ointment. LPA cross verified this information with text messages from R1's Home Health Nurse. Therefore the allegation " Staff not following residents care plan" is Substantiated. On the allegation "Resident sustained pressure injuries due to staff neglect" the following was found: On 11/4/2025 LPA A Gomez interviewed W1 and reviewed photos, and text messages from R1's Home health Nurse. R1 was admitted to the facility on 2/1/2025. LPA observed that on 2/7/2025 R1 did not have any pressure injuries on their bottom. On 2/11/2025 LPA observed that a pressure injury had began to form on R1's bottom but was not yet open. According to the Home Health Nurse the pressure injury was developing because of sitting for prolonged periods of time. Nurse advised for R1 to stand and walk every hour to prevent the wound from developing further. Between 2/12/2025 and 2/19/2025 it was documented that the pressure injury on the bottom had opened and developed further. Wound healed by 5/20/2025. Therefore the allegation "Resident sustained pressure injuries due to staff neglect" is Substantiated. Report continues on LIC9099-C Pg. 3 Continued On the allegation "Staff did not provide resident with a 60day notice of rent increase" the following was found: On 10/22/2025 LPAs A Gomez and A Gharachorloo conducted a visit to continue the investigation. During the Visit LPA's interviewed the Licensee/Administrator. During the interview when asked if they gave a 60 day notice of rent increase Administrator stated that, "they did increase the rent for R1 two (2) times because they needed a higher level of care; each time the rent was raised they state that they gave a 30 day verbal notice and that they were not aware that they needed to give a 60 day notice." On 11/4/2025 LPA observed text messages from Administrator stating that the rent would be increased the upcoming month due to R1's incontinence care, cost of living, and expenses and that if they did not agree they could submit a 30 day notice and leave the facility. R1 was admitted to the facility on incontinence care and there was not a change in condition. Therefore the allegation "Staff did not provide resident with a 60day notice of rent increase" is Substantiated. On the allegation " Staff are not meeting residents hygiene needs" the following was found: On 11/4/2025 LPA A Gomez conducted separate interviews with R1, and R2. Both R1 and R2 disclosed to LPA that the facility would monitor them while they were in the restroom and that they had to ask for toilet paper. R1 and R2 states that toilet paper was not readily available in the bathroom and that they would have to throw their used toilet paper away in the trash can. On 11/4/2025 LPA also observed messages from the Home Health Nurse stating that in April of 2025 they had found R1 with feces on their private parts and that they had to inform staff to clean R1. Therefore the allegation "Staff are not meeting residents hygiene needs" is Substantiated. Report Continues on LIC9099-C Pg. 4 On the allegation " Staff are not meeting residents dietary needs" the following was found: On 7/16/2025 LPAs observed during the initial complaint visit that R4 was thirsty and had not had any food or water since they had arrived at 1:00PM. LPAs had to request for staff to give R4 something to drink. On 8/20/2025 during a return visit LPAs observed that the food being prepared for residents lunch was expired. LPAs also observed expired canned goods, and food items in the refrigerator. On 10/22/2025 during a return visit LPA's inspected the refrigerator and observed additional expired foods in the refrigerator. On 11/4/2025 LPA interviewed W1. W1 provided text messages and photos of R1 being swollen because their no salt diet was nit being followed. W1 also disclosed that they witnessed staff attempting to prepare tater tots for R1 which goes against their dietary needs. Therefore the allegation " Staff are not meeting residents dietary needs" is Substantiated. On the allegation " Staff are not adequately trained" the following was found. On 7/10/2025 LPAs requested training records for all staff on the LIC 500. LPAs observed that all staff with the exception of the Administrator were not up to date on their training. Interviews with S1 concluded that they did not have the required knowledge to effectively conduct their role as a caregiver. Therefore the allegation "Staff are not adequately trained" 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. Pg. 2 On the allegation " Staff engaged in a verbal altercation in the presence of residents" the following was found: On 11/4/2025 LPA interviewed R2 who states that they would sometimes hear the Licensee raise their voice at caregivers. R1 was also interviewed but could not recall any altercations at the facility. During all visits LPAs observed that the Administrator can become elevated during discussions however it is attributed to their cultural expression rather than aggression. Therefore the allegation " Staff engaged in a verbal altercation in the presence of residents" is Unsubstantiated. On the allegation " Staff inappropriately using dirty washcloths" the following was found: LPAs did not observe any dirty washcloths during visits and no residents reported a concern of dirty washcloths being used on them. Therefore the allegation "Staff engaged in a verbal altercation in the presence of residents" is Unsubstantiated. On the allegation " Staff did not ensure resident received a copy of admissions agreement" the following was found: Based on interview with Licensee and W1 LPA was unable to conclude if the resident ever received a copy of the admissions agreement. Licensee states that they gave a physical copy of the agreement. Therefore the allegation "Staff did not ensure resident received a copy of admissions agreement" 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 report provided.