complaint·August 6, 2025

The investigation revealed the following: Allegation 1: Facility staff not providing adequate food service It was alleged that for the past months facility staff were not providing vegan meals. The resident often received only a slice of bread and some canned vegetable. On 05/12/2025 at 10:30 AM, LPA interviewed Assistant Administrator (A1), who denied the allegation, stating that "If a resident has a special diet, we follow the doctor's orders. It is posted in the kitchen and on the table. If they’re still hungry, snacks and an alternative menu are available.” On 05/12/2025, between 10:30 AM – 1:55 PM, and on 07/10/2025 between the hours, 9:55am - 9:57am, LPA interviewed 9 staff regarding the allegation: 9 of 9 staff denied the allegation. 1 out of 9 staff stated Resident 1 (R1) is the only is the only vegan resident and upon all resident admission, they request for dietary restrictions.  Also Staff 9 stated that the vegan resident is offered salad, tuna, sugar-free jello, sugar-free pudding, cottage yogurt. And further stated if the resident would like more food or alternative option available are chicken, vegetables, and green salad. Between 9:48 AM – 2:37 PM, LPA interviewed 11 residents: 1 of 11 residents confirmed the allegation, 4 of 11 residents denied the allegation and 7 of 11 residents were aware of the allegation. On 06/24/2025, LPA conducted a records review and observed the following: For Resident's 1 (R1) LIC 603 Replacement Appraisal Information, under the Social Factor section it states vegetarian and under the service needed, its check yes for special diet/observation of food intake is vegetarian, rice upsets stomach. For Resident's 1 (R1) LIC 625 Appraisal/Needs & Service Plan on page 1 of 4 it states under the background information section "Now she's on vegan diet, no rice. Rice upsets her stomach. On 07/10/2025, LPA conducted a tour of the kitchen and dining room and observed the following: Resident 1's dietary instructions and name tags are not post on the table of the dining room nor in the kitchen. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation 2: Facility staff are unable to communicate effectively with the residents It was alleged that the resident attempted to communicate with the kitchen staff, but they do not understand her because they only speak Spanish. On 05/12/2025 at 10:30 AM, LPA interviewed Assistant Administrator (A1), who denied the allegation, stating “Most residents here speak two to three languages. We have bilingual staff, and I also use Google Translate if needed. If there’s a barrier, we call the family or public guardian to assist.” Between 10:30 AM – 1:40 PM, LPA interviewed 9 staff regarding the allegation: 9 of 9 staff denied the allegation and stated that staff will collaboration with bilingual coworkers to overcome language barriers and or use of translation tools such google translator to communicate with the residents as needed. Between 9:48 AM – 2:37 PM, LPA interviewed 11 residents: 2 of 11 residents confirmed the allegation of which one of the residents expressed that staff ignored them, didn’t understand them, or failed to assist them when communication challenges arose. 8 of 11 residents denied the allegation stated that staff were helpful and compassionate, and communication was not an issue and 2 of 11 residents did not confirm or deny. Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. 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. No deficiencies were cited for the allegations above. An exit interview was conducted, and a copy of this report was provided to Christopher Redmond (In-Training Executive Director).