complaint·January 21, 2026

Allegation: Staff left resident in soiled bedding Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP/DPOA) staff (S1, S2) and reviewed resident (R1) documents. LPA interviewed RP who shared a photo taken while R1 was residing at the facility showing R1 wearing a soiled diaper with dried brown diarrhea on the side her buttocks as she rested on a soiled bed cover. 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 left resident in soiled bedding was found to be substantiated. Allegation: Staff did not ensure resident’s cup was free of mold Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP/DPOA) staff (S1, S2) and reviewed resident (R1) records. LPA analyzed two photos of R1's sippy cup which showed the presence of black mold inside the sipping straw and around the inside rim of R1’s stainless steel tumbler. 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 ensure resident’s cup was free of mold was found to be substantiated. Continued on next page, LIC9099-C pg1 Allegation: Staff did not ensure the facility was not in financial distress Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP/DPOA) staff (S1, S2) and reviewed resident (R1) documents. LPA interviewed RP who shared a photo of a water shutoff notice from the City of Antioch given to the facility dated 09/30/25 due to non-payment of service. S1 stated that water was cut off because ADM forgot to pay the water bill. RP also stated that on 11/12/25, the power was shut off by PG&E. S1 stated that ADM forgot to pay the monthly PG&E bill and that they were without power for approximately 10 hours until the bill was paid. 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 ensure the facility was not in financial distress was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) 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 did not ensure resident had video conference with physician Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP/DPOA) staff (S1, S2) and reviewed resident (R1) documents. LPA interviewed ADM who stated that she spoke with RP regarding the missed doctor video chat with R1 on 12/03/25. ADM stated she offered to assist RP and R1 reschedule the video call with her primary care physician. However, ADM stated RP did not follow-up with her again on the rescheduled video call. Review of text messages between RP and S1 in December 2025 showed staff informed RP that the facility phone did not have video chat capability to assist R1 with her scheduled doctor's video chat health evaluation on 12/03/25. Staff (ADM, S1) also stated that they offered to answer any questions during R1’s video chat to assist in R1’s health evaluation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not ensure resident had video conference with physician is unsubstantiated. Allegation: Staff did not notice resident’s change in condition Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP/DPOA), staff (S1, S2) and reviewed resident (R1) documents. RP stated she visited R1 the past two weeks in December 2025 and observed R1 having belly pain, loss of appetite, unable to sit up, incoherent and weak. RP stated she communicated her concerns about R1’s health condition with staff (ADM, S1, S2) in December 2025. On 12/03/25, ADM stated she spoke with RP and told her that R1 stated she was OK and did not want to see the doctor. ADM stated R1 told the staff she does not want to call the paramedics or 911. LPA interviewed staff (S1) who stated that they did not notice anything wrong with R1 while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not notice resident’s change in condition is unsubstantiated. Continued on next page, LIC9099-C pg2 Allegation: Staff did not seek medical attention for resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP/DPOA) staff (S1, S2) and reviewed resident (R1) documents. LPA interviewed RP who stated that she observed R1’s belly was distended for the past two visits. On 12/13/25, RP stated she observed R1 was barely able to tell her that it hurts when she applies pressure on her belly and noticed something was not right. She communicated R1’s concerns with staff (ADM, S1, S2) who offered to call the paramedics or take R1 to see her primary care physician. Staff (ADM, S1) stated that R1 refused to call the paramedics and told them she was fine and feeling well. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not seek medical attention for resident is unsubstantiated. Allegation: Staff did not ensure they repositioned resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP/DPOA) staff (S1, S2) and reviewed resident (R1) documents. Review of R1’s physician’s report and needs & services plan dated 07/02/25 did not show presence of any pressure injuries upon admission. Staff (ADM, S1) stated they repositioned R1 3X per day and that R1 did not have any pressure injuries while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not ensure they repositioned resident is unsubstantiated. Exit interview conducted. Appeal Rights and a copy of this report provided.