complaint·February 23, 2026

The investigation revealed the following: Allegation: Staff do not ensure resident's personal hygiene needs are being met. It was alleged that facility staff do not ensure the resident's personal hygiene needs are being met. The resident stated the last time they received a bed bath from facility staff was around 2 or 3 months ago. The resident mentioned that it has been around 1 year since receiving an actual shower. It was also reported that facility staff do not assist with personal hygiene which the resident needs assistance with. On 02/19/2026 between the hours of 8:42am - 8:49am, LPA interviewed A1 regarding the allegation. A1 denied the allegation. A1 stated the resident is scheduled to receive showers at least twice per week per the Admission Agreement , but indicated the resident often receives bed baths instead , reportedly twice a week , and that hygiene care is provided daily by direct care staff . A1 stated she does not personally assist with hygiene care , but that staff assist the resident with changing clothes, incontinence care, and brushing teeth on a daily basis . A1 acknowledged that deviations from showering may occur due to resident refusal or health-related issues (e.g., pain preventing movement) . A1 reported that the facility maintains records of bathing and hygiene care , and that staff are responsible for documenting care and reporting when hygiene supplies are low , at which point the family is notified or the facility provides items if needed . On 02/19/2026 between the hours of 9:21am -11:38am, LPA interviewed 5 staff in regards to the allegation. 2 of 5 staff confirmed the allegation and stated Resident 1 (R1) has been refusing showers since last year and cannot remember the last time R1 received a shower. Staff stated R1 gets bed baths usually twice a week but has been refusing. 1 of 5 staff did not confirm nor deny the allegation and stated the resident gets showers 3 days a week or upon request from the resident, and last month upon being assigned to the unit where R1 resides, personal hygiene assistance would be about 3 times a week. 2 of 5 staff were unaware of the allegation and stated they work in the memory care unit and do not assist R1 with showering or personal hygiene needs. Staff mentioned the facility keeps records using communication logs and shower sheets when residents are bathed or showered, and caregivers have to sign a shower sheet and document in the Activities of Daily Living (ADL) book. Investigation findings continue on LIC 9099-C On 02/19/2026 between the hours of 12:01pm - 2:11pm, LPA interviewed 10 residents in regards to the allegation. 2 of 10 residents confirmed the allegation. 1 of the 2 residents stated the last time they received assistance with a shower from staff is like months to a year. The resident stated it is not really often and once caregivers see the residents can independently take care of themselves, then no care is provided by staff even though the facility is supposed to provide care which is mentioned in their contract (Admission Agreement). Of the 2 resident who confirmed the the allegation mentioned staff are too slow with assisting and or never come, so they have to take their own shower because they cannot trust nor put their care in the hands of the caregivers. 1 of 10 residents did not confirm nor deny the allegation and stated staff help with changing and assist with their catheter, and about two weeks ago they had a bed bath. The resident stated they never refused bed baths/showers but would like a bed bath at least twice a week. 7 of 10 residents denied the allegation and stated they take their own showers independently, never ask for help since they do this themselves, take care of their own personal hygiene, and do not ask staff for help because they are independent. On 02/23/2026 between the hours of 8:30am - 11:00am, LPA conducted a records review and observed the following: According to the LIC 602A Physician's Report (dated 06/18/2024), page 5 of 9, Section 2 (Capacity for Self-Care), the resident is marked No for being able to bathe, dress, or groom self. Similarly, the LIC 603 Pre-Placement Appraisal Information (dated 07/04/2024) indicates Yes for needing help with bathing, hair care, and personal hygiene. Furthermore, the Admission Agreement under Section 3 (Basic Services), Item 8, specifies assistance with the following activities: a. dressing, c. toileting, d. bathing (twice weekly), and e. grooming. The shower logs for the month of February revealed R1's showers days are marked for Tuesdays and Thursday in the Spa Room. On the Resident Tracking Sheet (February 2026) for R1's during the AM, PM and NOC Shift it revealed: During the hours of 7am, 9am, 11am, 1pm, 3pm, 5pm, 7pm, 9pm, 10:30pm, 12am, 2am, 4am, 6am that S on the key which means for Supervised Safety was provided to the R1 on 02/01 - 02/05, 02/09 - 02/14, 02/17 - 02/18, 02/28 - 02/29. The following dates had no initials 02/06 - 02/08, 02/15 - 02/19 - 02/22. The facility did not provide written documentation of R1 refusing a shower and or bed bath. Investigation findings continue on LIC 9099-C The facility’s direct care staffing schedules from 02/08/2026 - 02/21/2026, stated the following: During the week of (02/08–02/14), the AM shift utilized 5 to 7 caregivers, the PM shift maintained 5 to 6 caregivers, and the NOC shift utilized 3 to 4 caregivers. Memory care coverage during this period consisted of 1 to 2 caregivers per shift. During the week of (02/15/2026 – 02/21/2026), staffing levels fluctuated, with the AM shift utilizing 4 to 7 caregivers and the PM shift utilizing 5 to 7 caregivers. The NOC shift had 2 caregivers on 02/16, 02/17, and 02/21. While memory care usually maintained 2 caregivers during the day, it dropped to 1 caregiver during the PM shift on 02/21 and remained at 1 caregiver for the majority of the NOC shifts throughout both weeks. Substantiated: Based on LPA's 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. Exit interview conducted with Catherine Dacara (Administrator) and a copy of this report was provided with appeal rights