Complaint·March 18, 2026

No active conflict was observed at the time of the visit. Records review revealed the following: Records for R1 indicate a diagnosis of end-stage renal failure requiring ongoing dialysis treatment and that R1 requires assistance with activities of daily living and supervision, including night supervision. Records for R2 indicate physical impairment requiring assistance with activities of daily living. LPA reviewed internal incident reports dated 03/12/2026 and 03/13/2026 documenting complaints regarding loud television use and roommate conflict between R1 and R2. Documentation indicates that R1 reported an inability to sleep due to the volume of the television, and staff provided reminders to R2 regarding house rules, including lowering the volume and using headphones at night. However, the facility did not provide additional requested documentation, including behavior logs, complaint logs, or records demonstrating ongoing monitoring, follow-up actions, or resolution of the roommate conflict. Records reviewed support the allegation, as the documentation confirms the reported concern and demonstrates that interventions were limited to reminders, without evidence of effective resolution, despite the resident’s medical condition requiring adequate rest and supervision. Regarding the allegation, “Facility did not maintain a safe and healthful environment for the resident,” it is being alleged that a resident was subjected to ongoing roommate conflict, including noise disturbances, lack of shared space access, and disruption of sleep, and that staff failed to ensure effective resolution of the situation. Interviews conducted revealed the following: Four residents (R1–R4) reported concerns supporting the allegation, while 10 out of 14 residents reported no concerns. Residents who reported concerns described ongoing roommate conflict involving loud television use at night, lack of respect, and misuse of shared space, as well as feeling unsafe due to roommate conflict and experiencing ongoing issues involving noise, hygiene concerns, and unresolved conflict lasting approximately six months. Interviews with 5 staff (S1–S5) supported the allegation, as staff confirmed that the roommate conflict between R1 and R2 has been ongoing for several months. Staff reported that R1 requires rest due to dialysis treatment, while R2 maintains a conflicting sleep schedule and uses the television at a high volume. Staff further reported that incident reports were completed and the issue was brought to administration, and that staff attempted verbal interventions such as reminders and mediation. S1 reported addressing the concern by counseling the resident, reviewing house rules, and offering a room change; however, both residents declined relocation, and the issue remained ongoing at the time of the investigation. Additional statements indicated that R1 may have difficulty reporting concerns due to language barriers. Please see (LIC9099-C) for report continuation. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation “Facility did not maintain a safe and healthful environment for the resident” is found to be substantiated. The facility identified the roommate conflict and implemented initial interventions; however, those actions were not effective, and the issue continued to impact the resident’s health and well-being. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87307(d)(2). A citation is being issued on the attached (LIC 9099D). An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to the Administrator.