complaint·August 21, 2025

Licensee does not provide adequate supervision resulting in neglect and lack of care to residents. During Interviews with staff it was revealed, licensee has adequate supervision to care for the residents. During interviews with residents, it was revealed that their needs are met, and staff respond to call buttons timely. During record review, it revealed the facility has two (2) staff members, house manager on AM shift and one (1) staff for the night shift. Licensee does not ensure that incontinent residents are kept clean and dry. During interviews with staff, it was revealed that R1 was the only incontinent resident and is changed after each meal and between meals throughout the day. During record review, it was revealed that facility has a changing schedule for incontinent resident. Licensee does not follow hospice care plan. During interviews with staff and hospice social worker, it was revealed staff were trained by the agency on handling R1’s daily needs. During record review it was revealed that R1 is a two person assistance,facility assist hospice assistant and facility does follow R1’s hospice care plan . Licensee does not ensure residents are repositioned which results in developing wounds . During interview with staff, hospice case manager, it was revealed that R1 is the only resident who is bedridden and on hospice that requires repositioning. During record review revealed, R1 is re positioned every four hours daily. Staff will retaliate against residents if they report to Ombudsman and CCLD. During interviews with residents, it was revealed that residents don’t feel they will be retaliated against if they were to report to the ombudsman or CCLD. R2 and R3 also stated during interview, that they both have a great relationship with staff and have never had any conversations with any of the staff regarding reporting to any agency. Continue on LIC9099C Continued from LIC9099C Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted with Paul Lam. A copy of this report provided. Continued from LIC9099 Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted with Paul Lam. A copy of this report and appeal rights provided