Complaint·June 3, 2026

LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The investigation revealed the following: Allegation: Facility staff mismanage residents’ medications. It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs assist with self-administered medications when LVNs are unavailable. A1 reported she was not aware of any missed doses or medication errors. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed ten (10) residents regarding the allegation. One (1) out of ten (10) residents confirmed the allegation. One (1) out of ten (10) was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. Of the one (1) resident who confirmed the allegation, the resident reported missed doses. Of the one (1) resident who was unsure mentioned being not sure of their medication management. On 05/13/2026 between 10:00am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and identified 42 undocumented medication administrations affecting eight (8) residents. The review showed missing initials for medications assigned to R1, including 6 missed doses of Carvedilol, 3 of Duloxetine, 14 of Furosemide, and 9 of Gabapentin on various dates in April 2026; R2 had 2 missed doses of Sacubitril/Valsartan, 2 of Magnesium Oxide, 2 of Vitamin C, and 1 multivitamin dose between April 10–18, 2026; R3 had 2 missed doses of AmoxClav, 1 of Olanzapine, and 1 Lidocaine patch between April 6–15, 2026; R4 had 2 missed doses of Polyethylene Glycol, 3 of Amlodipine, and 2 of Atorvastatin between April 12–20, 2026; R5 had 1 missed dose each of Benazepril, Eliquis, and Refresh Tears on April 9, 13, and 17, 2026; R6 had 2 missed doses of Divalproex, 2 of Vitamin D3, 3 of Docusate Sodium, 4 of Famotidine, 1 of Omega-3 Ethyl Esters, and 1 of Buspirone between April 5–22, 2026; R7 had 20 missed doses of Lantus Solostar, 3 of Metformin, and 2 of Xiidra throughout April 2026; and R8 had 2 missed doses of Levetiracetam and 1 missed dose each of Lisinopril, Sertraline, Acetazolamide, Bisacodyl, Ipratropium-Albuterol, Isosorbide Dinitrate, Jardiance, and Triamcinolone between April 7–25, 2026. The Department also observed nine (9) medications remaining inside bubble packs despite being initialed as administered, with no documentation explaining the discrepancies. Based on the Department'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 (Assistant Administrator) a copy of this report was provided with appeal rights. LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The Investigation revealed the following: Allegation: Facility staff do not ensure that residents’ toileting needs are met. It was alleged that residents were not receiving timely assistance with toileting and incontinence care due to chronic understaffing, resulting in delays in responding to care needs and insufficient break coverage. On 04/07/2026 between the hours of 8:40am - 8:52am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation, stated not being informed of any resident left soiled or any staff refusing assistance due to being on break. A1 explained that the facility uses a break schedule to ensure coverage and stated not being present during the reported incident and did not receive follow-up information. On 04/07/2026 between the hours of 11:55am - 1:33pm, the Department interviewed 5 staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not observed a resident being left soiled, had not refused assistance due to being on break, and stated that another caregiver is assigned to provide coverage when a staff member is on break. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents was aware of the allegation. Nine (9) out of ten (10) residents denied the allegation. Residents reported they independently manage toileting or receive timely assistance. One resident reported a single instance where staff stated they were on break in regards to the delay in responding to care needs. On 05/13/2026 between the hours of 10:00am - 11:00am, the Department conducted a records review of resident assessments and facility documentation and did not observe any records indicating unmet toileting needs or delays in incontinence care. 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: Facility staff did not treat residents with dignity and respect. It was alleged that staff entered rooms without knocking, spoke rudely to residents, and refused to provide their names. On 04/07/2026 between 8:40am -8:52am, the Department interviewed the Administrator (A1) regarding the allegation. A1 denied the allegation and mentioned not being informed of staff entering rooms without knocking, speaking rudely to residents, or refusing to provide their names. A1 stated staff are expected to knock before entering and identify themselves when asked, and no complaints of disrespectful conduct had been reported. On 06/03/2026 between 9:24am - 9:42am, the Department re-interviewed A1 to obtain additional information in regards to the allegation. A1 denied receiving any reports of staff entering rooms without knocking, speaking rudely to residents or visitors, refusing to provide their names, or making inappropriate statements. A1 stated staff are trained to uphold resident Personal Rights, including respectful communication and proper room entry procedures. A1 reported that R1 approached her the day after 04/02/2026 to apologize for R1's visitor’s behavior such as being rude towards the staff. A1 stated she spoke with the involved staff (S4), reviewed expectations regarding respectful communication, and reinforced de-escalation procedures. A1 reported no residents had expressed concerns about staff conduct or indicated a desire to move out due to staff behavior. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they knock before entering resident rooms, do not speak to residents in a rude manner, and provide their names when requested. Staff stated they were not aware of any incidents involving rude tone or refusal to identify themselves. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. Two (2) of ten (10) residents confirmed the allegation. Eight (8) of ten (10) residents denied the allegation. Two residents reported incidents involving rude tone or failure to knock; the remaining residents reported staff knock before entering and treat them respectfully. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of facility policies, resident rights documentation, and internal records and did not observe any documentation indicating staff failed to treat residents with dignity or respect. 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: Facility staff do not ensure residents’ medical needs are being met. It was alleged that residents were not receiving ordered physical therapy or medical services. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being aware of any resident failing to receive ordered physical therapy or medical services. A1 stated the facility follows up with therapy providers when services are missed and had not received reports of unmet medical needs. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) out of five (5) staff was unaware of the allegation. Staff reported they had not observed residents missing medical services and stated they notify the LVN or med-tech when residents report concerns. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported not receiving physical therapy; other residents reported receiving medical services as ordered or stated delays were due to insurance authorization rather than facility action. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of LIC 602s, LIC 603s, and medical documentation and did not observe any records indicating missed medical services or lack of follow up by the facility. 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 food served is of good quality. It was alleged that the food served to residents was of poor quality and did not meet nutritional needs, and that inadequate staffing and oversight contributed to inconsistent meal preparation and insufficient attention to dietary requirements. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated menus are created monthly and reviewed for nutritional adequacy. A1 reported not receiving complaints regarding food quality. On 04/07/2026 between the hours of 11:55am – 1:33 pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not received complaints regarding food quality and stated meals are prepared according to posted menus. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported dissatisfaction with food quality; other residents reported meals were satisfactory. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of the facility’s posted Spring 2026 menus for Weeks 1, 3, and 4. The Department observed that the menus were dated, organized, and reflected balanced meals including proteins, vegetables, starches, fruits, and desserts. Breakfast menus included hot cereals, eggs, pancakes, and juice options. Lunch and dinner menus included soups, salads, meats, vegetables, and desserts. The Department observed that the menus aligned with the facility’s Admission Agreement requirement to provide three nutritious meals daily and accommodate special diets. No documentation was found indicating that meals served failed to meet nutritional standards or that residents were served food inconsistent with posted menus or dietary requirements. 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 and a copy of this report was provided.