complaint·March 18, 2026

The investigation revealed the following: Regarding the allegation: Staff do not ensure that resident is taking medication as prescribed . It was alleged that morning medications are not administered properly. LPA's interview with two (2) out of three (3) residents present in the facility stated staff provide all medication prescribed. Interview with one (1) resident stated they have noticed the number of pills they are provided is different from one day to the next. They believe at least two medications have not be provided. LPA's review of the Centrally Stored Medication, Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR) revealed Resident #1(R1) had an alternative allergy medication prescribed with filled date 03/04/2026. LPA did not observe the medication documented on the MAR or CSMR. Review of the MAR revealed the originally prescribed medication was discontinued or no longer provided after 03/04/2026 without the new alternative medication being provided. R1 confirms they have not been provided the medication. LPA also observed an as needed or PRN medication with filled date 03/10/2026 was not documented in R1's MAR or CSMR. R1 confirmed they had not needed to request to take the PRN medication. The licensee stated they were not aware medication had changed or had been delivered and would immediately address the issue. S1 confirmed they have not provided the new medication. Based on LPAs observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. An exit interview was conducted, California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was given to administrator with the Appeal Rights. Regarding the allegation: Staff do not ensure that resident is provided comfortable living accommodations. It was alleged that resident(s) who smoke, are jeopardizing resident's health. LPA's review of the facility program only found that cigarettes should be kept inaccessible to clients with dementia and smoking is not mentioned in the program. According to the licensee nobody is allowed to smoke in the facility and the facility has a designated smoking area in the backyard. LPA's interview with two (2) out of three (3) residents present in the facility stated they smoke outside in a designated area and do not smoke indoors. Interview with one (1) of the three (3) residents stated although they have not witnessed residents smoking in the facility sometimes the door is slightly open and smoking residents are closer to the door then the designated area. Interview with S1 and the licensee deny anyone has smoked indoors and residents smoke in a designated area. 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. Regarding the allegation: Staff yelled at resident. It was alleged that the licensee yelled at a resident. LPA's interview with two (2) out of three (3) residents present in the facility deny being yelled at by the licensee and deny witnessing the licensee yell at another resident. Interview with one (1) resident stated the licensee had yelled at them with a raised voice after dismissing their concerns. Interview with S1 and the licensee deny yelling at residents or witnessing another staff yell at residents. S1 states residents may yell at staff. Interview with the licensee revealed he had a conversation with Resident #1 (R1) but he never raised his voice and plainly stated to the resident that if they are truly unhappy nobody was forcing the resident to stay since they felt they were trying their best to accommodate the resident's requests. The licensee went on to say they are not sure if this was the incident the allegation was addressing but it was the only conversation that stood out to them. LPA was unable to find a witness to the licensee yelling at residents. 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. Exit interview conducted. Copy of report provided to the administrator.