complaint·July 30, 2025

Allegation: Staff did not assist resident with incontinence care needs in a timely manner Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that on 07/23/25, RP called POA on his phone around 7:45 AM asking for help because his clothing and bedding were soaking wet and that staff was not responding to his calls (ringing his bell). Staff (S1) confirmed with LPA that they failed to assist R1 timely with his incontinence care needs because the other staff (S2) did not show up for her scheduled work at 6AM that day. LPA also interviewed R1 who stated that another staff (S3) changed his wet clothing, diaper and bedding around 9AM on 07/23/25 since S2 did not arrive at the facility until 10AM. 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(s) that staff did not assist resident with incontinence care needs in a timely manner was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates 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 made inappropriate comments to resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. S1 stated that POA arrived at the facility at around 8AM ringing the doorbell, banging the front door and yelling for staff to open the front door. S1 stated that when she opened the front door POA started yelling at her to assist R1 with his incontinence needs. S1 stated she told POA to stop yelling to avoid agitating the other residents. S1 denied making any inappropriate comments to R1 or POA. S1 stated she politely requested POA to leave the facility at around 8:15AM because she was continuing to yell and bang on the door. 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 made inappropriate comments to resident is unsubstantiated. Allegation: Staff interfered with resident’s visit Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. Review of R1’s admission agreement dated 02/10/25 showed that visitors’ hours are 7 days a week from 9AM to 7PM. S1 stated that on 07/23/25, POA arrived around 8AM ringing the front door vigorously, banging on the front door and yelling for staff to open the door. S1 stated that when she opened the door, POA went straight in and yelled for staff to R1’s wet diapers, clothing and bedding right away. S1 stated she was never rude to POA and requested her to leave the facility because she was yelling and disturbing the other residents. LPA reviewed S1’s cell phone calls on 07/23/25 which showed S1 called 911 at around 8:39AM which prompted the police to arrive at the facility around 9AM. S1 stated that she allowed POA to come inside the facility around 10:30AM when R1’s transport showed up for his medical appointment. 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 interfered with resident’s visit is unsubstantiated. Continued on next page, LIC9099-C pg2 Allegation: Staff retaliated against resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that staff (ADM,S1) started being rude to POA because ADM knew it was the POA who filed the previous complaints against the facility. ADM denied retaliating against POA. ADM stated she let POA attend their barbeque celebration with residents on 07/20/25 when R1 informed her of the event on 07/20/25. ADM also stated she answered POA’s text messages regarding R1’s relocation plans on 07/22/25. 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 retaliated against the resident is unsubstantiated. Exit interview conducted and a copy of this report provided.