complaint·August 27, 2025

The investigation revealed the following: Allegation #1- Staff left resident in soiled clothing for a period of time. The details of the complaint alleged that emergency services came to the facility on 08/20/25 because the resident (R1) was having difficulties that needed to be addressed. While at the facility it was reported that (R1) was observed to not have been cared for properly and smelled as though (R1) had not showered in weeks and was in soiled clothing. On 08/27/25, from 9:30am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that the resident has a history of refusing to shower and urinating on themselves as well as in their room. They state that they make every effort to change the resident when they discover that the resident has urinated or defecated on themselves but adds that the resident is very aggressive and combative when they try to change the resident. They further state that it takes several caregivers to achieve this, and it happens multiple times per day, but they do their best to keep the resident dry. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they were never left in soiled clothing for an extended period of time. They state that the staff is attentive to their needs, when assistance is needed. The department reviewed the Caregiver Daily Flow Sheet and Shower Schedule (Dated: 08/01/2025-08/31/2025) and Service Plan (Dated: 07/09/2025) and observed the resident has refused to take a shower on the following dates: 08/01/25, 08/03/25, 08/05/25, 08/06/25, 08/10/25, and 08/18/25 which were the resident’s scheduled shower days. The department did not find any evidence that the issue was being properly addressed by the facility knowing that the resident has these particular ongoing issues. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff left resident in soiled clothing for a period of time, is found to be Substantiated . California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Allegation #2- Staff not keeping resident’s room free from odor. The details of the complaint alleged that the staff does not ensure that the resident’s room is free from odor. It was reported that staff is not ensuring that the resident is not urinating in the resident’s room and therefore the resident’s room smells of urine. On 08/27/25, from 9:30am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff corroborated the allegation that Staff not keeping resident’s room free from odor. The majority of staff stated that the resident does urinate in their room and in their bed. They state that the resident’s room must be cleaned daily because the resident urinates in their urinal container and then pours it out onto the bed as well as on the floor. They further state that they make every effort to keep the room sanitized and clean and to change the resident often. However, this is an ongoing occurrence with the resident, stated staff. Report Continued on LIC9099-C The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that their room does not have any odors, and staff cleans their room daily. The department toured the resident’s room and observed that there is a strong urine smell as you enter the room, as well as stains on the carpet, which smells of urine. Based on observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation Staff not keeping resident’s room free from odor, is found to be Substantiated . California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations that are not cleared by the due date of 09/12/25 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiency was cleared at the time of the visit. Deficiencies were issued and plans of corrections were discussed. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.