complaint·July 24, 2025

Staff are not providing residents with adequate food service. On the allegation that the facility staff are not providing adequate food service, the concern of the reporting party (RP) is that R1 reported that they lost weight because the food was disgusting, and R1 was concerned about their protein intake. To investigate the allegation the LPA interviewed the staff and two current residents, and observed the refrigerator’s supply of perishable food, and the pantry for non-perishable food. The review of perishable and non-perishable food availability was observed to be adequate. Residents’ interviews revealed that they have sufficient food to eat, they get three meals a day, and snacks. The LPA interviewed R1, and the interview revealed that they did not care for the meals prepared by staff. Furthermore, R1 stated that they required a special diet, and staff did not provide R1 with the adequate fluids/beverages, that they lost . R1’s physician report and file review revealed that R1 did not have a special diet. The staff interviews revealed that they try to prepare eggs and toast in the mornings, oatmeal and cereals. For lunch they may prepare rice, fish, sausages, and vegetables. Although the allegation may have happened or is valid, based on the interviews, observation, and record review, there is not sufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed Unsubstantiated at this time. Staff do not provide linens for residents. On the allegation that facility staff are not providing residents with linens, it is alleged that R1 was not receiving towels as requested. To investigate the allegation the LPA conducted a physical plant tour to observe the linen supply of towels, sheets and blankets. The supply of linens and towels was observed to be adequate to serve six (6) residents at the time of the visit. LPA Urena interviewed R1, and R1 stated that staff would change the cloth hand towel hanging in the bathroom only once a week. Furthermore, R1 stated that staff would not provide the required paper towels in the bathroom. R1 stated that the staff refused to wash R1’s comforter, because it was not the one provided by the facility. Residents currently residing at the facility did not express concern about the linens. Staff denied changing cloth hands towels once a week or refusing to wash R1’s personal blanket. Staff stated that they change bed linens as often as necessary and/or once a week. Although the allegation may have happened or is valid, based on the interviews, observation, and record review, there is not sufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed Unsubstantiated at this time. Interview exit was conducted. A copy of the report was issued. Staff held retained resident at the facility against their will. On the allegation that staff held the resident at the facility against their will, it is the concern of the RP that the staff would not allow R1 to leave the facility. To investigate the allegation the LPA conducted interviews and reviewed records. The Administrator’s interview revealed that R1 would express that they wanted to go out on walks, but that staff was not able to accompany R1, so the Administrator would tell R1 that they could not leave the facility on their own, without staff going with them. Record review of R1’s physician’s report indicated that R1 was not able to leave the facility unassisted. The interview with R1 revealed that the door was not locked all the time, and they could possibly have been able to walk out the door, but the Administrator would threaten R1 not to allow them back into the facility if they left unassisted. Furthermore, R1 added that they saw a staff hammer a nail at the top of the front door. The nail was then bent to keep the front door from opening and was utilized to prevent another resident who consistently wanted to elope from the facility. The LPA conducted an inspection of the front door, and during the inspection observed that indeed, a bent nail was nailed to the frame of the front door, the nail could then be positioned against the door to prevent it from opening. Based on information obtained from interviews and observation, although the facility staff did not hold R1 from eloping by physically restraining them, language was used to threaten R1, and staff did not make accommodations for R1 to go on supervised walks. Furthermore, a nail was placed on the front door frame and used to keep the door from opening and preventing residents from going to the front yard of the house. Therefore, the allegation that staff held residents against their will, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and appeal rights was issued.