complaint·October 7, 2025

On the allegation " Staff are not properly supervising residents who may be a fall risk" the following was found: During interviews with staff on 8/7/2025 and 9/12/2025 were able to identify residents needs. LPA also observed sufficient coverage of staff on the day of the visits to meet the needs and services of residents. Based on observations of the staff schedule and staff on duty there is adequate supervision. LPA also briefly spoke to R3 who did not have any concerns with the care that they are receiving. On 9/12/2025 during PM shift LPA also tested call buttons in a random selection of rooms and staff were prompt to respond. Therefore the allegation "Staff are not properly supervising residents who may be a fall risk" 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. PG. 2 On the allegation "Staff are not meeting residents toileting needs" the following was found: During interviews with staff on 8/7/2025 and 9/12/2025 multiple staff reported that they have found residents wet and their beds "soaked" with urine during their shift. Staff made specific mention of R1, R2, and R3 being excessively wet on multiple occasions. During the interviews it was noted that residents are primarily found excessively wet at the start of the morning shift however it was mentioned that there have been occasions of excessive wetness on other shift. Multiple staff reported that they have reported concerns of residents incontinence needs not being met amongst other caregivers as well as leadership. LPA also attempted to interview R3 regarding incontinence but was unable to. Therefore the allegation of "Staff are not meeting residents toileting needs" is Substantiated. On the allegation " Staff are not providing adequate food service " the following was found: During interviews with staff on 8/7/2025 and 9/12/2025 there was a mixed review of the food being served at the facility. There were reports of the food being "ok", "good", and "healthy". There were also reports of the food "appearing under cooked" primarily the chicken. On 9/12/2025 the Health and Wellness Director (HWD) sampled the dinner meal of the day for the LPA and reported the food to have good flavor and quality. LPA observed the food that the HWD was sampling appeared to be of good quality. However upon inspection of the kitchen LPA observed that already prepared food to be served was not being stored properly and was left uncovered also sandwich supplies where also uncovered and not in use (ie. tomatoes, onion, lettuce, mayo, ect) . LPA also observed that there was a fly in the dinning/Kitchen area. LPA also inspected the food in the refrigerator/ freezer and observed some food in the refrigerator was moldy/expiring. LPA observed RAW chicken stored on top of produce in the refrigerator and open fish in the freezer. LPA also asked R3 about how they liked the food and they said it "sucked" but was unable to elaborate. Therefore the allegation of "Staff are not providing adequate food service" is Substantiated report continued on LIC9099-C PG. 3 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.