complaint·July 23, 2025

On 05/22/25, the department requested the following documents: staff roster, resident roster, and the shower schedule. The department conducted interviews with staff #1 - #7 (S1 – S7), residents #3 - #4 (R3 – R4), and attempted to interview residents #1 - #2 (R1 – R2). On 07/16/25, the department conducted interviews with staff #8 (S8), (R2), residents #5 - #10 (R5-R10), and attempted to interview R1. On 07/23/25, the department received the following documents: Medication Administration Records (MAR) for R1, R3, and R4, for the months of March, April, and May 2025, and the facility’s activities calendar for the month of June. Additionally, the department conducted a tour of the kitchen and dining room. The investigation revealed the following: Allegation: Staff are not providing residents with daily meals. It is being alleged that the facility is not providing a resident with their daily meals. It is also being alleged that the facility is not providing the resident with their dietary needs. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed, 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that residents receive three meals a day, including snacks in between. 8 out of 8 staff said that the facility does accommodate residents with special dietary needs. S1 stated that all residents receive three meals daily, including snacks, and that meals are determined based on their dietary needs. S1 said that if a resident has a special diet, the facility follows the doctor's orders, and it’s posted in the kitchen. If the residents are still hungry, snacks and alternative menu options are always available. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 7 out of 9 residents said that staff are providing them with their daily meals. 7 out of 9 residents stated that they had no complaints about the food being served at this facility. 7 out of 9 residents said this facility is meeting their dietary needs. The Department reviewed the Menu for the months of March, April and May 2025, and observed that the residents are getting a variety of nutritious foods for breakfast, lunch, and dinner. The menu was a healthy diet that emphasizes a wide variety of foods from all food groups, including fruits, vegetables, grains, lean protein sources (like fish, beans, eggs, lean meats) and dairy and dairy alternatives. On 07/23/25, the department conducted a tour of the kitchen and dining room and observed residents’ special dietary instructions posted on a board in the kitchen. Additionally, the department observed that residents were served lunch soup, vegetables, a turkey club sandwich, salad and chips. The department observed some residents immediately ate the food while others spent leisure time socializing along with their meals. 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. Allegation: Staff are not addressing resident bathing needs. It is being alleged that staff are not assisting a resident with bathing. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that staff assist residents with bathing 2-3 times a week. S1 said the caregivers are well organized, and they directly help the residents with their bathing needs. S1 said the facility has what they call “zones”, and each caregiver has their own zone. That caregiver gets to know the residents within that zone and offers to assist the residents with showers every morning. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 3 out of 9 residents said staff assist them with their bathing needs, while 6 out of 9 residents said they do not require any assistance with bathing. 7 out of 9 residents said they are satisfied with the services provided to them. The department reviewed the facility’s shower schedules for the months of March 2025 and May 2025. The department observed that residents are divided by zones 1-3, and each resident is scheduled to shower 2-3 times a week. 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. CONTINUED ON LIC9099-C Allegation: Staff are restricting residents from participating in activities. It is being alleged that a resident is being restricted from engaging in activities. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff said that residents are encouraged daily to participate in activities. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents said staff do not restrict them from participating in any activities. 7 out of 9 residents said they are satisfied with the services provided to them. The Department reviewed the facility's activities calendar, which featured daily events, social activities, arts and crafts, yoga, table games, bingo, karaoke and spa days planned for residents in care. 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. Allegation: Staff are financially abusing residents. It is being alleged that staff are withdrawing money from a resident’s account without their consent. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents said staff have not financially abused them. 9 out of 9 residents said they do not know if staff are financially abusing a resident. 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. CONTINUED ON LIC9099-C Allegation: Staff do not respond to residents’ call button in a timely manner. It is being alleged that staff are not responding to a residents call button. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed, 8 out of 8 staff denied the allegation. 8 out of 8 staff said that staff usually take 5 minutes to respond when a resident activates their call light. S1 stated that when a resident activates their call light or button, that call will go directly to the reception desk. The staff at the reception desk have radios, and they will radio a caregiver for assistance. S1 said they also have a paging system if needed. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents denied the allegation. 5 out of 9 residents said staff take about 5 minutes to respond when a resident activates their call light. 7 out of 9 residents said they are satisfied with the services provided to them. 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. An exit interview was conducted, and a copy of the report was provided to Christopher Redmond, Executive Director Intern. The department conducted interviews with staff #1 - #7 (S1 – S7), residents #3 - #4 (R3 – R4), and attempted to interview residents #1 - #2 (R1 – R2). On 07/16/25, the department conducted interviews with staff #8 (S8), (R2), residents #5 - #10 (R5-R10), and attempted to interview R1. On 07/23/25, the department received the following documents: Medication Administration Records (MAR) for R1, R3, and R4, for the months of March, April, and May 2025, and the facility’s activities calendar for the month of June. Additionally, the department conducted a tour of the kitchen and dining room. The investigation revealed the following: Allegation: Staff are not dispensing medication as prescribed. It is being alleged that the facility is not administering a resident’s medication as prescribed. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that staff administer the resident’s medication on time and as prescribed by their physician. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 7 out of 9 residents said that staff administer their medication on time and as prescribed by their physician, and 2 out of 9 residents said staff do not administer their medication on time and as prescribed. On 07/23/25, the department reviewed MAR’s for R1, R3, and R4 for the months of March, April, and May 2025. The records revealed discrepancies, and various medications were missed on various dates for R1, R3, and R4, for the months of March, April, and May 2025. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited. Please see the attached LIC 9099-D. An exit interview was conducted, and a copy of the report was provided to Christopher Redmond, Executive Director Intern.