Complaint·May 20, 2026

The investigation revealed the following: Allegation: Staff mismanaged resident medication It was alleged that for the last 3 months a resident medications have been passed out late. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 who denied the allegation and stated the facility uses a medication cart for medtech to administer the medication to the residents. A1 also stated the facility just suspended two (2) medtech for lack of performance and Technical Support Program (TSP) provided by the Department of Social Service Community Care Licensing came to the facility about two weeks ago to assist with medication training. On 11/13/2025, between 9:15am - 1:21 pm, , the Department interviewed 9 staff regarding the allegation. 2 of 9 staff confirmed the allegation and stated due to short staff and or stopping to help assist another resident there have been challenges with timely medication administration. 2 of 9 staff denied the allegation and stated not rushing to administrator medication quickly to avoid making a mistake while another staff stated it's hasn't been any challenges with timely medication administration. 5 of 9 staff were unaware and or have no knowledge of the allegation due to their assigned job roles such a receptionist, caregiver, and activities director. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 4 of 10 residents confirmed and stated by R1 that medication were for 3 months while other residents such as R3, R7 and R9 stated their medication being given late or missed once before. 3 of 10 residents denied and stated never experienced receiving their medication being given late nor missed. 3 of 10 residents did not confirm nor deny the allegation due to R6 stating no comment while R8 stated not remembering and R10 have not having any knowledge of their medication being give late or missed. On 11/19/2025, between the hours of 9am - 11am, LPA conducted medication review for 10 residents (R1 - R10) and observed the following: Medication Administration Record (MAR) for November 2025 indicated the medtechs administered medication by initial & timestamp. However medication is still observed to be in the bubble for Resident 1 (R1) 8pm Pregabalin 150mg on 11/1, 11/04, 11//11 and 11/18, Resident 1 (R1) 6:30am Pantoprazole SD DR 40 on 11/01 , Resident 5 (R5) 8pm Rosuvastatin Calcium 10 MG on 11/09, Resident 5 (R5) 6:30am Pantoprazole SD DR 40 MG on 11/01 and Resident 9 (R9) 8pm Atorvastatin 40 MG on 11/13, 11/14 and 11/15 Based on the Departments 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: Facility does not have a certified Administrator It was alleged that the facility does not have a certified Administrator since Michael Mendoza. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 who stated Melissa Flores is currently acting as the facility Administrator and is not sure how long she's been in the position. A1 stated she has a Administrator certification. On 11/13/2025, between 9:15am - 1:21 pm, the Department interviewed 9 staff regarding the allegation. 9 of 9 staff denied the allegation and stated Jennifer Rivas has been acting as the facility Administrator for a couple months. On 11/13/2025, between 8:29am- 2:00pm, the Department interviewed 10 residents regarding the allegation. 1 of 10 resident denied the allegation and stated Jennifer Rivas is the current Administrator of the facility. 9 of 10 are unaware of the allegation. On 11/17/2025, between the hours of 2:20pm - 2:30pm, the Department conducted a records review and observed the following: The previous Administrator for the facility was Michael Mendoza. Upon the departure of Michael Mendoza, the facility had Melissa Flores acting as the Administrator who held a Administrator Certification effective 08/11/2023 - 08/11/2025. On 11/7/2025, the Department received an email from Jennifer Rivas who provided her Proof of Completion for Certification Program for 740 - Residential Care Facility for the Elderly effective as of 02/23/2024 - 02/23/2026. Unfounded: This agency has investigated the complaint alleging (for the allegation above). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted with Catherine Dacara (Assistant Administrator) and a copy of this report was provided. The investigation revealed the following: 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, the Department 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, the Department interviewed 9 staff regarding the allegation. 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, the Department interviewed 10 residents regarding the allegation. 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, the Department 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 1:00am and 11:00pm 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 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. On11/13/2025 between 9:15am - 1:21pm, the Department interviewed 9 staff regarding the allegation. 9 of 9 staff denied the allegation and stated they receive in-service training on a regular basis. On 11/13/2025, between 8:20am - 2:00pm, the Department 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 them. On 12/16/2025, between 8:35am - 11:15am, the Department conducted a records review and observed that the facility conducted twenty-nine (29) in-service trainings between January 28, 2025 and September 29, 2025. Each training included a sign-in sheet acknowledging staff participation and understanding of the material presented. Topics covered during these training included new employee orientation; sexual harassment (1 hour); workplace violence (1 hour); injury and illness prevention; bloodborne pathogens (30 minutes); missing resident response procedures; dementia and memory care practices (5 hours); activities of daily living and personal care; medication administration; infection control (3 hours); residents’ rights and mandated reporting; fall and elopement safety; housekeeping and food safety practices; activity programming; customer service (3 hours); and applicable facility policies and procedures. On 05/18/2026, between 11:00am -12:00pm, the Department conducted an additional records review (requested training on multiple dates such as 04/03, 04/17, 05/13) of personnel files for A1 and S1–S10 which included training certificates, medication training documentation, shadow training logs, and facility in-service sign-in sheets. The review revealed that all eleven (11) staff had completed the required New Employee 20-Hour Training, with completion dates ranging from 2021–2025. Nine (9) staff had current Sexual Harassment Prevention Training, and six (6) staff completed Workplace Violence Prevention Training in 2024–2025. Four (4) staff completed the 8-hour Medication Technician Training, and three (3) staff completed the full Basic Medication Training Course supported by 16-hour medication shadow-training logs documenting instruction in medication ordering, storage, documentation, medication passing, refusal procedures, and communication. 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, the Department 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, the Department 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, the Department 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 11/26/2026 between the hours of 11:16am - 11:25am, the Department 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 (Assistant Administrator) and a copy of this report was provided.