Complaint·December 17, 2025

Allegation: Staff are not adequately trained. It was alleged that there are many staff members who are not trained. On 11/13/2025, between the hours of 11:12am - 11:22am, LPA interviewed A1, who denied the allegation and stated that in-service training for staff is conducted once a month, and this month's training will address fall risk. Between 9:15am - 1:21pm, LPA interviewed 9 staff members: 9 of 9 staff denied the allegation and stated they receive in-service training on a regular basis. Between 8:20am - 2:00 pm, LPA interviewed 10 residents: 8 of 10 residents denied the allegation and stated the staff know what they are doing when helping residents and have not noticed a difference between newer staff and those who currently work or formerly worked at the facility. 2 of 10 residents did not confirm nor deny the allegation; R6 stated "no comment," while R8 stated doesn't think much about it because they don't know which staff are new and that does not involve himself. On 12/16/2025, between 8:35am - 11:15am, LPA conducted a records review and observed the following: For 2025, the facility conducted twenty-nine (29) in-service training's between January 28, 2025, - September 29, 2025. Each training included a sign-in sheet acknowledging staff participation and understanding of the material presented. Topics covered during these trainings included new employee orientation; sexual harassment; workplace violence; injury and illness prevention; bloodborne pathogens; missing resident response procedures; dementia and memory care practices; activities of daily living and personal care; medication administration; infection control; residents' rights and mandated reporting; fall and elopement safety; housekeeping and food safety practices; activity programming; customer service; and applicable facility policies and procedures. A total of 46 employees work for the facility, with 18 out of 46 staff members being caregivers. Of the 18 caregivers out of the 46 staff have not completed all the required training per Title 22 regulations and health & safety code. Based on LPA's observations and interviews that 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, Chapter 8, as cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Administrator) and a copy of this report with appeal right was provided. Allegation: Staff do not ensure resident diapering needs are met It was alleged that residents are not getting their diapers changed in a timely manner. On 11/13/2025 between the hours of 11:12am - 11:22am, LPA interviewed A1 denied the allegation and stated staff conduct rounds to ensure resident who need diaper changes are assigned promptly. On 11/13/2025, between 9:15am - 1:21 pm, LPA interviewed 9 staff: 7 of 9 staff denied the allegation and stated upon the call light going off, caregiver are radio over the walkie-talkies to assist the residents and also resident are changed every 2-3 hours or upon the residents’ request. 2 of 9 staff did not confirm nor deny the allegation but stated at time sometimes when the facility is short staff it does affect how quickly the resident receive diapering care needs. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 2 of 10 residents denied the allegation and stated that they are in fact incontinent but expressed the staff check and change them, once in the morning and once in the night or 3 times in the afternoon and 2 times in the middle of the night. 7 of 10 residents did not confirm nor deny and state that they are not wearing diapers because they are not incontinent 1 of 10 residents had no knowledge of the allegation and stated no comment at the time of the interview. On 12/16/2025, between 1:30pm -2:30pm, LPA conducted a records review and observed the following: The facility has 35 incontinent residents. According to incontinence logs for September through November 2025, 33 residents received incontinence care, including bowel movements, toileting, supervised toileting for safety, showers, wet or dry briefs, or care was refused. Care was documented at various times throughout the day and night, ranging from overnight (NOC) to hourly intervals between 1:00 aam and 11:00 pm Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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 do not ensure that resident's with special dietary needs are adequately fed It was alleged that residents who require a special diet are not accommodated. On 11/13/2025 between the hours of 11:12am - 11:22am, LPA interviewed A1 denied the allegation and stated that residents with special diets or food allergies are identified on a list created by the front desk, which is posted in the kitchen. A1 also stated that if a resident cannot eat what is being served, an alternative menu is offered. However, if the resident does not want anything from the alternative menu, the facility will ask the resident what they prefer and will try to accommodate their request as much as possible. Between 9:15am - 1:21 pm, LPA interviewed 10 staff: 10 of 10 staff denied the allegation and stated the facility has documentation such a binder on file and the whiteboard located in the kitchen which list the residents special diets and food allergies. Staff also states the facility has other options such as sandwich, chicken, yogurt , Jello, rice pudding and fruit as alternative food. Between 8:29am - 2:00pm, LPA interviewed 10 residents: 1 of 10 residents confirmed the allegation and stated the facility does not handle their dietary preferences at all with no healthy alternative options provided as a result of purchasing their own food for the last two years. 8 of 10 residents denied the allegation and stated not asking for something specific and did not experience being served food they couldn't eat. 1 of 10 resident did not confirm nor deny the allegation and stated being allergic but the facility doesn't give them avocados. However one time the resident was served veal and can't eat veal. On 11/13/2025 at 12:11pm, LPA conducted a tour of the kitchen and dining room and observed the following: A white board which states 12 of the residents are diabetic, 2 of the residents are allergic (for R6 jelly, lemonade, no red drinks) and no shellfish for another resident. For R1 no dairy products, no bell peppers, no red meat (only turkey). For 2 residents of one being R7 food must be puree. Also for one of the residents no meat. On 11/26/2026 between the hours of 11:16am - 11:25am, LPA conducted a record review a observed the following: Resident 1 (R1) LIC 602A Physicians Report for Residential Care Facilities for the Elderly (RCFE) - (dated 07/27/2023 page 3 of 6 states under the physical health status e. special diet is checked no. Also, the GPLB Resident Summary Sheet (spreadsheet), stated that the facility requested Resident 1 (R1) Physician Report on 08/19/2025. Resident 1 (R1) provided a Rx from Vannarith So, MD Internal Medicine (dated 12/21/2023) states patient (R1) is lactose intolerance, intolerance to bell pepper and allergic to bleach. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. Exit interview conducted with Catherine Dacara (Administrator) and a copy of this report was provided.