complaint·October 15, 2025

Continued from LIC 9099 Regarding allegation “Resident was left in soiled diaper for extended period of time” it was alleged that R1 was left in a soiled diaper for more than ten (10) hours. Interviews conducted reflected the R1’s family was notified by the facility ED that R1 had not been checked since 5:45 P.M. on the evening of 09/29/2025. Information gathered during the course of the investigation reflected that, the ED made a typographical error when corresponding with R1’s family and inadvertently stated P.M. vs A.M. Per the ED, the information was inaccurate as the night shift begins at 10:00 P.M. and ends at 6:00 A.M. the following day. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Resident was left in soiled diaper for extended period of time” is deemed unsubstantiated at this time. Continued from LIC 9099 It was alleged that “Staff failed to treat resident with dignity or respect”. It was reported that in March 2025, Staff #1 (S1) intentionally fed Resident #1 (R1) dog food, allegedly as a joke. After receiving a formal complaint and speaking to the Reporti ng Party (RP), LPA reviewed the facility’s history and determined that on 04/09/2025 a Case Management (CM) visit had been conducted by LPA E. Cortez regarding the incident involving R1. Evidence reviewed during that visit, including the facility’s incident report and the report of suspected dependent adult/elder abuse form (SOC341) submitted by the ED on 03/21/2025 to Community Care Licensing (CCL), confirmed that the incident had occurred. According to the SOC341, ED acknowledged that S1 fed R1 food from a bowl with paw prints containing dog food, rather than from the community’s kitchen bowl containing Spaghetti prepared for residents. The facility’s internal investigation further confirmed that S1 was laughing about the incident and shared details of their actions with other staff members. R1 did not ingest the dog food and reportedly spat it out immediately. Following the incident, the ED contacted R1’s responsible person and their physician and removed S1 from employment as of 03/31/25. Additionally, all staff were retrained on mandated reporting requirements and abuse prevention procedures. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. As a result, the allegation of “staff do not treat residents with dignity or respect” ha s been SUBSTANTIATED at this time. However, this issue was previously addressed during a case management visit conducted on 04/09/2025, at which time citations were issued. Therefore, no citations will be issued today. Regarding allegation of “Staff failed to meet resident incontinent needs while in care”. It was alleged that facility’s staff left Resident #1 (R1) covered in feces from head to toe in R1’s bed. Interviews conducted reflected that on 09/30/2025, at approximately 8:45 A.M., R1’s family member found R1 covered with urine and feces. Additionally, it was also revealed that prior to this incident R1 was often found in briefs saturated with urine in the morning. Continued on LIC 9099-C Continued on LIC 9099-C Staff interviews conducted revealed that R1 can be resistant to care at times, becomes easily agitated, and would often refuse showers or care-related assistance. Additionally, even though there is no documentation stating R1 requires frequent monitoring, staff who provide care to R1 stated that due to R1’s condition, R1 requires more frequent monitoring. Additionally, it was revealed that all staff are aware that R1 should be checked at least once every hour. During the interview, staff #2 (S2) reported that on the morning of 09/30/2025, at approximately 6:10 AM, the night shift staff (S3) verbally informed them that R1 had been cleaned and did not require further assistance at that time and proceeded with their regular morning duties, responding to other residents who called for assistance without checking on R1. An interview with the ED revealed that S2 acknowledged that they relied on the information provided by S3 and did not verify R1’s status during the transition between shifts. During today's visit, the LPA reviewed the facility's camera footage from the date of the reported incident. The footage showed that S3 entered R1's room at approximately 5:16 AM and exited at 5:17 AM. The next individual observed entering R1's room was the family member, who arrived at approximately 8:52 AM. Based on the information gathered and record reviewed during the investigation, the department has sufficient evidence to confirm this allegation occurred. As a result, the allegation of “Staff failed to meet resident incontinent needs while in care” has been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.