Complaint·March 19, 2026

Allegation: Staff did not allow residents access to hygiene products Investigation Finding: Substantiated During investigation, LPA observed each memory care resident has their own private bathroom with a sink and a locked cabinet underneath where their personal hygiene items/toiletries such as shampoos, body wash, soap, toothpaste, conditioners, etc. are stored. Staff (former ED, MCD) confirmed with LPA that each memory care resident’s hygiene products are locked inside the cabinet and that memory care residents cannot access their own toiletries, soap, and personal hygiene items without the caregivers using a universal key to unlock the cabinet. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff did not allow residents access to hygiene products was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Staff confined resident to room Investigation Finding: Unsubstantiated During unannounced visits on 10/03/24, 11/22/24, 01/15/25, LPA observed memory care residents eat their meals in the common dining areas and participate in group recreational activities assisted by staff. During investigation, former Executive Director (ED) and Memory Care Director (MCD) stated that staff did not confine residents to their room. Staff stated that memory care residents are encouraged/assisted by staff to participate in daily meals and scheduled recreational activities. On 03/20/26 at 9AM, LPA spoke with third party (W1) who confirmed that on 09/29/24, RP grabbed her cell phone and inputted his contact information without her permission while sitting at a common area in the memory care unit. W1 stated she was very agitated with RP's aggressive behavior, immediately deleted the unwanted information he inputted in her cell phone and reported the incident to management. Former ED and Risk Manager (RM) stated that they had several discussions with RP regarding his disruptive and threatening behavior towards residents, guests and staff during his visits to the facility. After receiving more complaints from residents, guests and staff about RP’s aggressive behaviors, RM sent a final notice to RP dated 11/12/24 limiting his visits to R1’s apartment only. Review of resident’s (R1) signed Residency and Service Agreement dated 09/29/23 showed facility staff reserves the right to remove or deny entry to the Community to any visitor whom they determine to be disruptive or dangerous.” Par 23.g. Based on records review, interviews conducted, and observations made, the Department has investigated the above allegation that staff confined resident to room and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff confined resident to room is unsubstantiated. Exit interview conducted and a copy of this report provided to ED.