complaint·January 21, 2026

Continued LIC9099-C page 4. Allegation #5: Staff did not ensure resident was cleaned during diaper changes. LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that staff assist residents with diapering and ensure diapers are changed every two hours or as often as needed based on individual needs. 4 out of 4 staff members confirmed that proper hygiene practices are followed during diaper changes, including cleaning the resident before applying a new diaper. 4 out of 4 staff members stated that staff do not instruct residents to urinate in their diapers. 4 out of 4 staff members stated that residents are not left in soiled diapers for extended periods and do not exhibit a foul odor. S1–S4 denied the allegation. LPA also interviewed residents #2–6 (R2–R6). One resident (1 out of 6) stated that staff change their diapers regularly and th at they are never left in soiled diapers. 1 out of 6 residents stated that staff cleans them appropriately during diaper changes. 4 out of 6 residents stated that they do not wear diapers and are independent in their toileting needs. R2 denied the allegation. During the visit, LPA observed staff performing diaper changes during the visit and noted that staff followed proper hygiene protocols, including cleaning the resident before placing a new diaper. No evidence was observed to support the allegation. Allegation #6: Staff did not serve an adequate amount of food to residents in care. LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that residents are served an adequate amount of food. Staff confirmed that residents receive three meals per day plus snacks and have access to an ample supply of both perishable and non-perishable food items. 4 out of 4 staff members explained that residents are provided with more than enough food and are allowed second servings. If a resident does not like what is being served, alternative options are available. S1-S4 denied the allegation. LPA observed residents eating lunch during the visit and verified that the facility’s food supply was sufficient. The observed meal included generous portions, and staff followed the posted menu. LPA also reviewed the facility’s food menus from May 2025 through July 2025 and confirmed compliance with meal planning requirements. See continued LIC9099-C page 5. Continued LIC9099-C page 3 LPA reviewed the facility’s incident and injury logs for the past six months and found no documentation of unexplained injuries regarding the resident. During the visit, LPA observed residents in care and noted no visible injuries or signs of neglect. No evidence was found to support the allegation. Allegation #3: Staff not allowing a resident to use the restroom. LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that residents are always allowed to use the restroom as needed and that staff do not restrict access. Staff explained that residents are encouraged to use the restroom independently, and assistance is provided only when requested or necessary. S1–S4 denied the allegation. LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated that they are free to use the restroom whenever they need to and stated that they are independent and do not require staff assistance for restroom use. R2–R6 denied the allegation. LPA observed residents moving freely throughout the facility during the visit, including access to restrooms without staff interference. No evidence was observed to support the allegation. Allegation #4: Staff are not allowing a resident to use a medical device. LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that residents are allowed to use their prescribed medical devices according to their physician’s orders. 4 out of 4 staff members explained that they assist residents with medical devices when needed and ensure proper usage for safety and compliance. S1–S4 denied the allegation. LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated they are allowed to use their medical devices without restriction and reported no issues or interference from staff. R2–R6 denied the allegation. LPA observed residents during the visit and noted that medical devices were present and in use as appropriate. LPA reviewed residents’ medical records and confirmed that physician orders for medical devices were documented and followed. No evidence was found to support the allegation. See continued LIC9099-C page 4 Continued LIC9099-C page 2. Unusual Incident/Injury Report (dated 02/10/2024 & 02/16/2024), Sign In and Out Sheet (dated 01/2025--02/2025), and Flex Note (2/17/2025, 02/21/2025, 03/01/2025, 03/02/2025. and 03/04/2025. On 12/19/2025, between 10:00 a.m. and 3:00 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#4 (S1–S4) and with residents #2–#6 (R2–R6). Resident #1 (R1) was unavailable for an interview as they no longer reside at the facility. R1 transferring to a higher level of care facility. The investigation revealed the following: Allegation #1: Staff handled the resident in a rough manner. LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that facility staff did not handle any resident in a rough manner. 4 out of 4 staff members stated that no staff member caused a resident to cry or slam a resident’s wheelchair to the ground while the resident was seated in it. S1–S4 denied the allegation. LPA interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated that the staff has never handled any resident roughly. 5 out of 6 residents reported that staff provide a safe and comfortable environment and would never harm a resident. 5 out of 5 residents reported feeling safe in the facility and stated that staff cares about their well-being. 5 out of 6 residents reported being happy with the staff and the care they are receiving, and they had no problems or concerns. R2–R6 denied the allegation. LPA observed staff interactions with residents during the visit and noted that staff were respectful, gentle, and attentive to residents’ needs. No evidence was found to support the allegation. Allegation #2: Resident sustained an unexplained injury while in care. LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that no resident sustained an unexplained injury while in care. Staff explained that any injuries are documented immediately, and incident reports are completed and submitted to the Department as required. S1–S4 denied the allegation. LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated they did not witness any resident sustaining an unexplained injury while in care. Residents reported feeling safe and confirmed that staff respond promptly to any concerns. R2–R6 denied the allegation. See continued LIC 9099-C page 3. Continued LIC9099-C page 5 LPA interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated they receive three meals per day plus snacks and have plenty of food to eat. Residents stated they are satisfied with the meals provided and had no complaints about the food. R2–R6 denied the allegation. LPA inspected the kitchen and pantry areas and confirmed that the facility maintained the required two-day supply of perishable foods and seven-day supply of non-perishable foods, in accordance with Title 22 regulations. No evidence was found to support the allegation. Allegation #7: Staff did not prevent the facility from being unkempt. LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that the facility is cleaned daily and maintained in good condition. 4 out of 4 staff members explained that cleaning schedules are followed consistently, including sanitizing common areas, resident rooms, and bathrooms. S1–S4 denied the allegation. During the visit, LPA observed the facility to be clean, organized, and in good repair. Floors, furniture, and bathrooms were free of dirt and clutter, and no safety hazards were noted. The facility appeared well-maintained and met Title 22 requirements for cleanliness and sanitation. LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated that staff cleans the facility every day and confirmed that the environment is kept neat and sanitary. Residents reported no concerns regarding cleanliness. R2–R6 denied the allegation. LPA reviewed the facility’s housekeeping schedule and confirmed that daily cleaning tasks are documented and completed. No evidence was found to support the allegation. See continued LIC9099-C page 6 Continued LIC9099-C page 6 Allegation #8: Staff illegally evicted a resident in care. LPA interviewed staff members #1–4 (S1–S4). S1 and S2 stated that staff did not illegally evict the resident and confirmed that the resident never received an eviction notice. 2 out of 4 staff members explained that the resident required a higher level of care due to increased needs and was referred to a locked memory care facility for safety and supervision. S3 and S4 stated they do not handle eviction matters and had no knowledge of any illegal eviction. 4 out of 4 staff members stated that the this facility is an assisted living facility where residents are free to come and go as they please. S1 and S2 stated that no formal eviction process occurred. S1–S2 denied the allegation. LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated they were not aware of any illegal eviction and stated that they themselves had not received an eviction notice. R2–R6 denied the allegation. LPA reviewed the resident’s file and observed documentation indicating that the resident’s condition had changed, requiring a higher level of care. The facility followed proper procedures by notifying the responsible party and assisting with the transition to an appropriate care setting. No evidence was found to support the allegation of an illegal eviction. Allegation #9: Staff left residents in a soiled diaper for a long period of time. LPA interviewed staff members #1–4 (S1–S4). All four staff members (4 out of 4) stated that residents are not left in soiled diapers for extended periods. 4 out of 4 staff members explained that residents are checked and changed every two hours or more frequently as needed to maintain hygiene and comfort. S1–S4 denied the allegation. LPA also interviewed residents #2–6 (R2–R6). All five residents (5 out of 6) stated that staff do not leave residents in soiled diapers and stated that staff respond promptly when assistance is needed. R2–R6 denied the allegation. See continued LIC9099-C page 7 Continued LIC9099-C page 7 LPA observed staff providing care during the visit and noted that proper diapering procedures were followed. LPA reviewed the facility’s care logs, which documented regular diaper checks and changes in accordance with the facility’s policy and Title 22 regulations. No evidence was found to support the allegation. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-Cs was provided to Lorenzona Medina, Administrator. No deficiencies were cited during this visit. An exit interview was conducted.