complaint·January 6, 2026

Regarding the allegation “Staff do not ensure resident's room is clean and sanitized.”, it is being alleged that items in a resident’s room were discovered dirty. Record reviews have revealed the following: a cleaning log was provided, which indicates that staff members have completed their housekeeping work. Housekeeping work includes cleaning the restroom, taking any dirty dishes that may have accumulated in a resident's room and sanitizing the mattress before fitting a new sheet. Interviews have revealed that all seven (7) residents (R1-R7) and all four (4) staff (S1-S4) have disagreed that the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff does not ensure resident is provided clean linen.”, it is being alleged that staff do not change bedsheets within residents’ room. Record reviews have revealed the following: a cleaning log was provided, which indicates that staff members have completed their housekeeping work. Housekeeping work includes sanitizing bed mattresses prior to fitting any new sheets, cleaning the restroom and taking any dirty dishes that may have accumulated in a resident's room. Interviews have revealed that all seven (7) residents (R1-R7) and all four (4) staff (S1-S4) have disagreed that the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff does not ensure facility elevator is in good repair.” It is being alleged that the elevator is in disrepair. LPA observed there are two (2) elevators in the facility, one (1) of them in disrepair while the other elevator assists residents to ambulate through the facility. Record reviews have revealed the following: the elevator went out of service on 12/23/25. Prior to this date, the elevator had given prior notice as the elevator would shudder to a stop there have been two (2) inquiries and two (2) quotes provided to repair the broken elevator. Interviews revealed that all seven (7) residents (R1-R7) and three (3) out of four (4) staff are aware of the elevator in disrepair. While one (1) out of two (2) elevators are out of service, there is still one (1) out of two (2) elevators in working condition. Based on observation, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Report continues, please see LIC9099-C. Regarding the allegation “Staff does not ensure emergency drills are being conducted.” It is being alleged that emergency drills have not been conducted. Record reviews have revealed the following: quarterly in-staff training regarding fire (kitchen fire), Disaster drill (gas leak w/ fire) and Evacuation Drill (natural gas explosion (dated: 05/15/25). LPA requested most recent quarterly drill, but Fire Safety Service has relocated offices and the files will not be available during today's visit. S1 provided all-staff quarterly training's on Shingles / 911 Calls (dated 09/16/25) / Physician's orders & Facesheet (to ambulance driver(s)) (dated 11/13/25), which indicates the facility is conducting quarterly staff training's under a variety of conditions. Interviews revealed that two (2) out of seven (7) residents have indicated that they know where to go during an emergency drill, yet according to Health and Safety code (HSC) 1569.695(c), "An actual evacuation of residents is not required during a drill.". All four (4) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated . There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Maria Galvan - Executive Director (S1) and a copy of this report has been provided.