Complaint·May 13, 2026

(Continued from LIC9099) LPA conducted interviews with an additional ten (10) residents and three (3) staff members. On 10/16/2026 LPA Rios conducted an interview with an additional resident. On 05/06/2026 LPA Rios requested and obtained copies of R1’s documents such as Physician’s Report (LIC602), and Resident Appraisal from the facility. The investigation revealed the following: Regarding the allegation, staff discriminate against a resident in care . It is alleged that staff treated a resident differently from other residents. LPA’s interview with sixteen (16) out of twenty (20) residents stated they had not been discriminated against by staff. Three (3) residents stated they may have experienced discrimination at some point in the past by staff but were not sure when. They reported they don’t feel that way now. One (1) resident stated they felt staff were friendlier toward other residents than toward them. The residents could not provide a timeframe, identify who was involved, or describe any specific discriminatory actions. Interviews with nine (9) staff denied any discriminatory conduct and stated they have not witnessed residents being discriminated against by other staff. Staff also reported not receiving complaints from residents related to discrimination. 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 at this time. Regarding the allegation, staff do not treat a resident with dignity. It is alleged staff ridiculed resident in care. Interviews with seventeen (17) out of twenty (20) residents stated they had not been made fun of by staff. Two (2) residents stated they believed staff talk among themselves and felt staff laugh at them but could not hear what is said. Interviews with nine (9) staff indicated they have not made jokes about residents nor witnessed other staff making jokes or inappropriate comments toward residents. Staff reported they feel comfortable bringing any concerns to management or addressing the issue directly with the staff involved. 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 at this time. Continue to LIC 9099-C Regarding the allegation, staff did not respond to a resident's call light. It is alleged staff did not respond to resident’s call light when resident needed assistance to the bathroom. Interviews with sixteen (16) residents revealed that they had pushed the call button/call light for assistance. Three (3) of which stated they were independent and did not need to call for assistance. Seven (7) out of the sixteen (16) residents stated that had called for assistance reported call-light response times were fine, while three (3) out of the sixteen (16) reported to have waited 1-3 hours and five (6) out of the sixteen (16) reported wait times varied with the longest being 30 minutes and it depended on the shift but also reported staff provided a reason for a delay on response time. Interviews with nine (9) staff reported that they typically respond within 5 minutes, stating they go straight to the room and turn off the call-light button, unless they are already assisting another resident. Staff also state they communicate with other staff if they cannot make it to the room so that someone else can assist the residents. LPA conducted a test of four (4) call buttons in 4 resident rooms and staff responded within five minutes or less. On 10/13/26, LPA reviewed the facility’s call light log and observed two rooms where call lights were tested earlier to which staff responded, continued to show the calls as active. According to the receptionist, staff may forget to turn off the call light after assisting someone or the call light might be on in error. 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 at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was provided.