Complaint·February 10, 2026

The investigation revealed the following: For the allegation: Staff did not administer medication to a resident in care. It is being alleged that staff frequently run out of the resident’s prescribed medication, resulting in the resident not receiving the medication. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 6 out of 7 residents could not corroborate with the allegation. 6 out of 7 residents said they are receiving their medication(s) on time and as prescribed by their physician. An interview with R1 revealed that they missed their medication one day, but that they understood it was out of the facility’s hands, and the pharmacy was behind. R1 said that she is overall satisfied with their services at the facility and has no complaints. On 01/08/26, LPA Gonzalez conducted a review of records. LPA reviewed R1’s MAR for the months of December 2025 - January 2026 for R1 and observed them to be in order. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. 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. For the allegation: Staff did not prevent a resident from interrupting another resident's sleep. It is being alleged that a resident’s roommate frequently disrupts their sleep by making noise and arguing with caregivers, and that staff do not intervene. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 8 out of 8 residents could not corroborate with the allegation. An interview with R1 revealed that there were a few occasions when R1 was awakened by their roommate and staff. R1 stated they understand that staff were assisting the roommate with activities of daily living. R1 reported that they have since spoken with both their roommate and staff regarding the issue, have reached an understanding, and stated that the situation has improved and is currently going well. Continued on LIC9099-C Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. 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. For the allegation: Staff are not following resident's care plan. It is alleged that staff are required per the resident’s care plan to brush the resident’s hair and have not done so since December 26, 2025. On 01/08/26, LPA Gonzalez interviewed S1–S7. Of those interviewed, 4 out of 4 staff denied the allegation. On 01/08/26, LPA Gonzalez conducted interviews with residents R1–R7. Of those interviewed, 7 out of 7 residents could not corroborate with the allegation. An interview with R1 revealed that staff had just brushed their hair earlier that day, and that they are satisfied with the services provided to them by staff at the facility. On 01/08/26, LPA Gonzalez reviewed R1’s Individual Service Plan and did not observe a requirement for staff to brush R1’s hair daily is a part of the service plan. Based on observation, records reviewed, and interviews conducted, there is insufficient evidence to support the allegation. 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. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided to Azucena Reyes.