complaint·April 28, 2026

The investigation revealed the following: Allegation: Staff does not ensure resident is provided a bed in good repair. It was alleged that the resident’s bed was removed due to the suspected infestation and that a replacement bed was not provided in a timely manner. As a result, the resident reportedly slept in a chair in a common area overnight. It was also alleged that the resident would not have an appropriate bed available upon returning to the facility after medical treatment. On 04/28/2026 between the hours of 9:13am – 9:48am, the Department interviewed Administrator (A1) regarding the allegation. A1 denied the allegation and stated becoming aware of the bed bug concern in room 86B on 04/21/2026 when the resident reported it. A1 stated that during the night of 04/21/2026 going into the morning of 04/22/2026, staff removed the resident’s from their bedroom to address the infestation, laundered the resident’s clothing, provided a shower, and supplied clean clothing. A1 stated the resident was immediately offered a temporary room (87A) with a bed, but the resident refused and chose to remain in the common area. A1 stated the resident later requested to go to the emergency room at the direction of her social worker and was transported on 04/22/2026. A1 stated the resident returned on 04/24/2026 and agreed to stay in temporary room 87A until room 86B could be treated. A1 stated the facility’s protocol requires a replacement or temporary bed to be provided immediately when a bed is removed and that pest control services were contacted to conduct heat treatment in all affected rooms. On 04/28/2026, between the hours of 11:48am – 1:16pm, the Department interviewed Staff (S1–S11) regarding the allegation. 2 out of 11 staff were unaware of the allegation. 9 out of 11 staff denied the allegation . Staff reported that the resident in room 86B was offered relocation to a temporary room with a bed. Staff stated the facility maintains multiple new replacement beds and that maintenance is responsible for bed replacement. Several staff reported that the resident chose to remain in the common area despite being offered a room with a bed. No staff reported that the resident was denied a bed or that a replacement bed was unavailable. Report continues on LIC 9099-C On 04/28/2026, between the hours of 10:00am – 12:08pm, the Department interviewed Residents (R1–R11) regarding the allegation. Based on resident interviews, 1 out of 11 residents confirmed the allegation , 7 out of 11 residents denied the allegation , and 3 out of 11 residents were unaware of the allegation . The resident who confirmed the allegation repo rted sleeping in the lobby due to not having a suitable bed available and stated they was instructed to continue sleeping in their bed despite K9 detection of bed bugs. The other residents who were unaware of the allegation did not report being without a bed nor bed not being in good repair. The remaining residents who denied the allegation expressed not experiencing any issues with their beds nor sleeping arrangements and mentioned feeling safe and comfortable in their rooms. On 04/28/2026, between the hours of 1:23pm - 1:45pm, the Department conducted a record reviews, a physical plant tour and observed the following: the Resident Roster (received & printed on 04/28/2026) verify the room assignment for all the residents who reside at the facility. The beds in Room 7A, Room 11A, Room 16, Room 30B, Room 78A, Room 86B, and Room 87A to be in good repair. Beds were observed to be intact, stable, and free of visible damage or safety hazards with the bed frames or mattresses being in good condition during the walk-through. Based on information gathered through interviews, record reviews and observation, there is not enough 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. Exit interview conducted with Joe Saldana (Administrator) and a copy of this report was provided.