complaint·November 22, 2025

In regard to the allegation” Staff do not ensure that resident has clean bedding”, It is alleged that R1’s bedding had urine on it and staff refused to change bedding. During interview with Administrator, and staff six (6) out of six (6) stated that bedding is cleaned once a week or as needed. During initial visit on 11/06/2025 LPA observed R1’s bedding stained with urine. R1 stated to Administrator that he/she had asked the night before for linen to be changed and Administrator stated staff would be there today at 3:00 PM to change it. During visit on 11/18/2025 LPA observed room 9 and room 17 to have urine-stained bedding. Interviews with residents, four (4) out of seven (7) stated that they have had urine-stained bedding or witnessed other residents with soiled linen. R1 stated that they are supposed to change bedding weekly but get too busy to do it. R7 stated one time they had an accident and when staff was asked to change sheets, they stated that it’s not my job wait till another staff gets here, forcing S7 to wait till the next day. In regard to the allegation” Staff interacts with residents in an inappropriate manner”, It is alleged that staff (S6) refuses food and or snacks and is rude to residents. During interview with Administrator, and staff six (6) out of six (6) stated that they have never interacted with a resident in an inappropriate manner nor ever witnessed another staff treating residents inappropriately. Administrator stated that a complaint was made about S6, and he/she was spoken to but later that day witnessed the resident shaking hands with that staff. During interviews with residents five (5) out of seven (7) stated that S6 denies them food by telling them kitchen is closed. R1 stated that S6 is rude and calls him/her names. R7 stated that S6 tosses plates at them when serving food, is rude, and has denied them food. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Andrea Flores. In regard to the allegation” Staff speaks inappropriately to resident”, It is alleged that S6 calls residents out of name. During interview with Administrator, and staff six (6) out of six (6) stated that staff has never called a resident out of their name. S6 stated that with difficult residents another staff will usually assist so they can take care of residents together. During Interviews with residents five (5) out of seven (7) stated that staff has called them out of their name. R1 stated that staff is rude and calls me names. In regard to the allegation” Staff do not ensure the facility is free of insects”, It is alleged that facility has bugs in the bedrooms. During interview with Administrator, and staff six (6) out of six (6) stated in the past they have had issues with bugs but have been spraying the facility and working with Orkin. Staff stated that the insects’ problems have gotten better. During interviews with residents five (5) out of seven (7) stated that they have seen bugs in the past but that they are taking care of the problem by spaying the rooms. LPA obtained copies of invoices from Orkin pest control that showed monthly services are being conducted however Administrator stated something else was needed to treat the bug issues and has set up service with a new provider Squash Pest Control Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Rosalie Sandoval, Executive Director and a copy of this report was provided.