complaint·November 3, 2025

Regarding: Staff forced residents to wear bibs. It is alleged that staff is forcing residents to wear bibs during mealtimes. Staff deny the allegation. Interviews with seven (7) out of (7) staff revealed that staff do not force residents to wear bibs/clothes protectors during mealtimes. Staff indicated that the bibs are placed on residents after getting consent for those who need help with feeding. Staff indicated that the bibs help prevent residents’ clothes from getting stained, particularly for those who have their food pureed. Staff further indicated that residents can remove the bib at any time during or after their meals. Interviews with (6) residents revealed that they are not forced to wear bibs during mealtimes. LPA, attempted to interview R7-R9 but R7 and R8 did not respond to LPA’s questions and R9 was not at the facility during visit. LPA, conducted observation during the lunch meal service and did not observe any staff forcing residents to use a bib while being helped with their feeding. Staff and resident interviews and LPA observation do not corroborate the allegation that residents are being forced to wear bibs. Regarding: Staff did not follow proper hand hygiene procedures when assisting residents in care. It is alleged that staff is assisting multiple residents in their room without changing their gloves between residents. Staff deny the allegation. Interviews with (7) out of (7) staff revealed that staff change their gloves between residents in care. Staff indicated that they follow proper hand hygiene and glove protocols when caring for residents. Staff further indicated that gloves are not reused between residents and that gloves are for one-time use. Staff stated that gloves are properly removed and disposed of to prevent contamination as indicated by the training they receive regarding glove use. Staff also stated that the facility has sufficient gloves for all staff to use and when supply becomes low, staff can replenish glove stations with boxes from the supply closet in the med-tech area. Interviews with (6) out of (9) residents indicated that they have no concerns about the use of gloves by staff. Three residents did not provide a statement about the use of gloves by staff. LPA inspected the facility’s glove supply and observed to have sufficient gloves for the use of staff. Further observation of the facility by LPA indicated that the facility has glove holders on the walls of both wings by resident rooms in a variety of sizes, and boxes of gloves are also kept in the bathroom and in the med-tech carts. Staff and resident interviews, and LPA observations, do not corroborate the allegation that proper hand hygiene procedures are not being followed by staff when assisting residents in care. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated . An exit interview was conducted, and a copy of this report was provided. The investigation revealed the following: Regarding: Staff did not clean and disinfect items shared between residents in care. It is alleged that bibs are not washed and that staff is reusing them with other residents. Interviews with (4) out of (7) staff revealed that bibs/clothes protectors are used on residents during mealtimes to prevent their clothes from being stained with pureed food. Staff indicated that if bibs are observed not to be soiled during breakfast after being used on a resident, the bib is then placed on the dining room cart and saved to be used again during the lunch meal service. Staff further indicated that after lunch, staff will then place the soiled bibs removed from residents into the laundry hamper located in the dining room and the night shift will proceed to wash them and have them ready for the dinner meal service. Staff further indicated that the bibs are washed daily; however, they are washed after the second meal service by the night staff after bibs have been used for breakfast and lunch. Interviews with (2) staff further indicated that at times, it is hard to tell which bibs were used by a particular resident during breakfast and bibs may be placed on a different resident during the lunch meal service. During tour of facility, LPA inspected (6) bibs which were folded and stored on a cart in the dining room. LPA observed (4) out of the (6) bibs to have food stains. Staff indicated that the bibs inspected by LPA were going to be used again today for the lunch meal service and had not noticed that the bibs were soiled. LPA attempted to conduct interviews with (8) residents but they were unable to answer questions asked by LPA. R9 was unable to be interviewed due to being away from the facility during visit. Staff interviews and LPA observation corroborated the allegation that items are not clean and disinfected between resident use. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report and Appeal Rights were provided.