complaint·February 24, 2026

It is alleged that facility Administrator (S1) is forcing all residents to sign documents authorizing Administrator to speak to the social security office on resident’s behalf. On 02/18/26 from 10:00 am- 11:am LPA conducted Interviews with R1-R6 regarding the allegation above. 5 of the 6 residents interviewed denied the allegation above, 1 of the 6 residents interviewed confirmed the allegation above. Additionally, 2 of the 6 residents interviewed reported being their own payee, 2 of the 6 residents interviewed reported that a family member is their payee, and 2 of the 6 residents interviewed reported that they are unaware of who is their payee. On 02/18/26 from 11am - 12pm LPA conducted interviews with S1-S6 regarding the allegation above. During interview with S1, S1 denied the allegation above and reported that the facility Is not the payee for any of the residents at the facility. S1 continued the state that the facility has residents sign an ACH form which is a direct deposit form for the room and board. During interviews with S2-S6 regarding the allegation above, 5 of 5 staff denied the allegation above and reported they have not observed Administrator asking residents to sign any documents. Allegation: Facility staff are retaliating against residents for filing complaints. It is being alleged that facility Administrator (S1) has threatens to throw residents out if they complain about issues at the facility. On 02/18/26 from 10:00 am- 11:am LPA conducted Interviews with R1-R6 regarding the allegation above. 6 of the 6 residents interviewed denied the allegation above. 5 of 6 residents interviewed stated they have not expressed any concerns the Administrator or filed complaints about the care they are receiving, 1 of the 6 residents interviewed reported expressing concerns about the care being received directly to the Administrator. On 02/18/26 from 11am - 12pm LPA conducted interviews with S1-S6 regarding the allegation above. During interview with Administrator (S1), S1 denied the allegation above and reported that residents are spoken to and reminded of the facility rules rather than serving an eviction notice. During interviews with S2-S6 regarding the allegation above, 3 of the 5 staff interviewed denied the allegation above, 2 of the 5 staff interviewed reported that they do not have any knowledge regarding the allegation above. On 02/18/26 LPA reviewed a copy of eviction notice issued on 12/04/25, eviction notice was issued to a former resident who required a higher level of care, eviction notice appeared to be incompliance with title 22 regulation. Allegation: Staff does not ensure residents are spoken to in an appropriate manner. It is being alleged that facility Administrator bullies and speaks inappropriately to residents in care. On 02/18/26 from 10:00 am- 11:am LPA conducted Interviews with R1-R6 regarding the allegation above. 6 of the 6 residents interviewed denied the allegation above. Additionally, 3 of the 6 residents interviewed reported feeling respected by staff, 2 of the 6 residents interviewed reported they do not feel respected by staff, 1 of the 6 residents interviewed reported they sometimes feel respected by staff. On 02/18/26 from 11am - 12pm LPA conducted interviews with S1-S6 regarding the allegation above. During interview with Administrator (S1), S1 denied the allegation above and reported that residents have reported that staff are mean, but residents have not used the word “bully.” Per S1, S1 will investigate when residents make these reports. During interviews with S2-S6 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. Allegation: Staff does not ensure medications are dispensed in a timely manner. It is alleged that facility staff did not provide resident in care with nighttime medication(s). On 02/18/26 from 10:00 am- 11:am LPA conducted Interviews with R1-R6 regarding the allegation above. 5 of the 6 residents interviewed denied the allegation above and reported they are always provided with their medication. 1 of the 6 residents interviewed confirmed the allegation above, however resident stated being informed by staff that medications were not available due to insurance issues. On 02/18/26 from 11am - 12pm LPA conducted interviews with S1-S6 regarding the allegation above. 5 of the 6 staff interviewed denied the above allegation. 1 of the 6 staff interviewed confirmed the allegation above but stated it is only when the facility is waiting for medications to be delivered. Allegations: Staff falsify records. It is being alleged that the facility Administrator (S1) falsifies documents when licensing comes to inspect the facility. On 02/18/26 from 10:00 am- 11:am LPA conducted Interviews with R1-R6 regarding the allegation above. 5 of the 6 residents interviewed denied the allegation above. 1 of the 6 residents interviewed confirmed the allegation above and resident stated resident believes Administrator has altered residents’ records. On 02/18/26 from 11am - 12pm LPA conducted interviews with S1-S6 regarding the allegation above. 4 of the 6 staff interviewed denied the allegation above, 2 of the 6 staff interviewed reported they do not have any knowledge regarding the allegation above. Allegation: Staff does not ensure food is of good quality and quantity. It is alleged that the facility staff will serve a bowl of soup and half sandwich with no second helping. On 02/18/26 from 10:00 am- 11:am LPA conducted Interviews with R1-R6 regarding the allegation above. 6 of the 6 residents interviewed denied the allegation above and reported that second servings are provided when they request them. On 02/18/26 from 11am - 12pm LPA conducted interviews with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the above allegation and reported they have not observed any issues with the food being served. Additionally, 2 of those 6 staff reported there is an alternative menu residents can choose from if residents do not want to eat the items on the regular menu. 5 of 6 staff interviewed reported that second servings are provided upon request, 1 of the 6 staff interviewed stated being unaware if a second serving is provided when requested. On 02/18/26 LPA Villegas observed lunch service and conducted tour of facility kitchen. LPA Villegas observed meals provided to be of good quality and quantity, residents were provided with protein, vegetables, and a piece of bread. LPA Villegas observed the food to be fresh as LPA toured facility kitchen, LPA also observed pantries, refrigerators, and freezers to be well stock as facility just had a delivery during the time of visit. LPA Villegas reviewed the facility menus for January 2026-February 2026 as well as the alternative menu. LPA Villegas observed the menu to be different every day, LPA Villegas observed a list of items residents can choose from off the alternative menu. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, and a copy of this report was provided.