complaint·September 16, 2025

On 8/1/2025 LPA conducted tests on residents call button. LPA found that R1's pendant was not working properly and that staff were not notified when it was pressed therefore they were not able to meet the residents need in a timely manner. LPA asked staff when they came to help R1 get ready for meal time if they received a notification for R1's pendent being pressed and they stated "no". During the observation Health and Wellness Director was present. Therefore the allegations are substantiated. ***LPA assessed a civil penalty for repeat violation ($250)*** 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. On 9/12/2025 LPA reviewed ledgers for a sample of residents. LPA observed that there was a substantial credit for R1. LPA spoke with BOD and ROS regarding the credit to see if they were connected to the allegation of " Staff charged resident for services not rendered". LPA found that the credit was because the resident was overcharged due to an accounting error. LPA reviewed R1's careplans from 2023-present and found that the level of care has not changed. LPA however did observe on one of the careplans that a special code was not inputted correctly which triggered the extra charges. On 8/1/2025 LPA visited with R1, R2, R3 and R4. LPA observed that R1 was refusing care as outlined in their careplan. R2, R3, and R4 did not note any concerns with the level of care that they were being provided and LPA did not observe any concerns. LPA was unable to interview R1 however R2, R3 and R4 all expressed satisfaction with the staff and did not express any concern with staff speaking to them inappropriately. On 9/12/2025 LPA spoke with BOA who stated that there was a concern with an interaction between S1 and R5 however it was found that it did not indicate S1 speaking inappropriately to R5. Therefore the above allegations are 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.