Complaint·September 16, 2025

Allegation: Staff do not ensure that facility is maintained at a comfortable temperature for residents. The complaint alleges the air conditioning in residents rooms on the second floor and in the dining room is set too cold and residents complain about being uncomfortably cold. A total of eight residents were interviewed. The majority of the residents interviewed live in the 2nd floor. Three (3) out of eight (8) residents stated the air conditioning in their room was set too low and as a result they were uncomfortably cold. Maintenance staff closed the vents in the room. Per staff interviews, typically the facility temperature is set between 72-74 DF. On 5/23/2025, a physical plant inspection was conducted with Administrator Logan Harrison's assistance. The common areas and dining room were comfortable in temperature. However, 4 out of 7 rooms inspected on the 2nd floor were cold, below 72 DF. Room #207's room temperature measured 62 DF, and rooms 209, 211, and 215 were cold below 72 DF. The findings indicate that room temperature in some of the 2nd floor rooms is controlled by the thermostat in room 207. During today's visit, LPA checked a total of 13 rooms. The temperature in the rooms was within required temperature range. However, there is sufficient evidence to support the allegation. Allegation: Staff do not ensure the facility is free of tripping hazards. It is alleged that a resident fell in the dining room because of uneven flooring. Three (3) out of eight (8) residents confirmed R2 fell in the dining room. Staff interviews confirmed that on April 29, 2025, at approximately 12:30 PM, resident (R2) fell while dancing and walking in the dining room. The incident resulted in a femur fracture and surgery. Staff confirmed some areas in the dining room have peeling laminate flooring. Based on physical plant observations on 5/23/25 and today, the findings indicate the center left flooring in the dining room has a section of raised laminate flooring of approximately 7 inches that poses a tripping hazard. Pictures were taken during the visits. As of today, the flooring has not been repaired. Interim Administrator stated contractors will be coming to the facility in the next couple of weeks to evaluate the flooring issue and determine a repair plan. There is sufficient evidence to support the allegation. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview conducted, copy of the report and appeal rights was provided to Interim Executive Director Mario Preston. Allegation: Staff speaks inappropriately to residents. It is alleged that there is a caregiver that talks down to people and argues with residents. According to information obtained, residents are afraid and intimidated with caregiver/staff (S1). A total of 8 residents were interviewed. One out of eight residents stated S1 said to them to mind their own business and shut up, when the resident asked S1 to bring another resident their sweater because the dining room was too cold. Staff (S1) denied the allegation, and stated that on the contrary, a Sunday in May 2025 a resident yelled at S1 called them derogatory names in front of residents in the hallway by the dining room. All staff denied the allegation. The majority of the residents interviewed stated staff (S1) is respectful, treats residents well, and the staff person has never spoken to them inappropriately. Allegation: Staff interacts with residents in an inappropriate manner. The complaint alleges that caregiver/staff (S1) rubbed resident (R1's) back and shoulders when they were standing near the front desk. According to information obtained, the physical touch was unwelcome. One (1) out of eight (8) residents stated that in April 2025, they were at the front desk and S1 came from behind and rubbed their shoulders, which made them feel uncomfortable and shocked, but it was not reported to Administration staff. The majority of residents interviewed stated they have not been inappropriately touched by S1 or any other staff. All staff interviewed denied the allegation. Staff (S1) stated that R1 does not receive any assistance with activities of daily living and is independent, and there has been no physical contact with R1's shoulders. Administration staff looked into the allegation, and determined that S1 may have in the past pat R1's back in passing, but nothing more than that. Per staff interviews, Brookdale policy allows staff to pat residents in the back and hug them if the resident welcomes it. Staff also stated that some residents ask staff for a hug and/or like a pat in their back. All staff stated that if and when a resident is touched it is appropriate. Allegation: Staff do not ensure elevators are in good repair. It was reported that one of the facility elevators has not worked since late 2024, early 2025, and the licensee has decided not to fix the elevator because the parts are obsolete. All residents interviewed confirmed the allegation. One (1) out of 8 residents stated that although there is another operable elevator, it is an inconvenience to walk to the working elevator. Staff interviews revealed that the rear elevator has had issues since January 2025, and stopped working completely in March 2025. A work order was put in March 24, 2025. The elevator was evaluated and it was determined the mother board and two cylinders are not working. According to staff, the facility has 2 elevators, and the other elevator closest to the dining room continues to be operable. As of today, the elevator remains inoperable because the parts needed are still at the manufacture level. However, since the facility has one elevator that works, the allegation cannot be supported. Allegation: Staff do ensure resident's room is clean and sanitary. It is alleged that rooms were cleaned once a week, but a new housekeeper staff was hired and they cleaned resident (R1's) room every 2 weeks, and did not wash bed sheets weekly. One (1) out of 8 residents agreed with the allegation. Another resident stated that their room is cleaned once a week, but their sheets are not washed weekly. Staff interviews revealed that light housekeeping is done once a week, and personal belongings and bed linens are laundered once a week. The rooms are cleaned in rotation. According to interviews, a housekeeper/staff (S4), called out a couple of Saturdays, which was R1's room cleaning day. Administrator stated that when a staff person calls off it is communicated to other housekeepers and overtime is offered. During both visits, LPA inspected resident rooms to determine cleanliness and to check the condition of the bed sheets. The rooms were observed clean and bed sheets were not observed dirty. On 5/23/25, S4 was observed cleaning resident rooms, and during today's visit S6 was observed cleaning and washing clothes and bed linens. There is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated . Exit interview conducted with Interim Executive Director Mario Preston. A copy of the report was issued.