Complaint·April 30, 2026

Prior to the visit, LPA interviewed Resident #1(R1) and staff#1(S1). LPA interviewed two family members of R1, a Hospice Nurse, a Cal Aim placement coordinator, and a Family friend of R1, who shall be referred to as W1 through W5. The investigation reveals the following: Regarding "Staff do not notify the residents' responsible party of a change of condition," it is alleged that the facility failed to inform R1’s responsible party when R1 fainted. According to the Administrator, R1 fainted twice: the first time, R1 was admitted to the facility, and the family was updated; the second incident sent R1 to the hospital. Both times, R1’s family was notified. W1 stated that R1 fainted about 3-4 times and that each time they were under the impression that the family knew. R1’s responsible party believes that R1 doesn’t faint but gets long-winded whenever moving a certain distance. Staff interviewed stated that it was 2-3 times R1 had fainted, and each time Hospice and family were notified. They further stated that there was never any change in R1's condition. The investigation reveals the following: Regarding "Staff do not assist residents with ADLs," it is alleged that the facility does not assist R1 with baths when hospice is not present. LPA interviewed the Administrator, who stated that the facility provides R1 with a bath as needed and that hospice comes twice a week to provide a bath. All staff interviewed stated they have always assisted R1 with ADL’s, including bathing as needed. All residents stated the facility provides them with a proper bath and brief changes. W1 stated that whenever they are at the facility, R1 is always clean. The investigation reveals the following: Regarding “Staff did not allow a resident to eat food," it is alleged that S1 did not allow R1 to eat the ice cream provided by W2. LPA interviewed the Administrator, who stated that they are unaware of the incident. All staff interviewed denied the allegation, stating that they had never withheld food from the residents. 5 out of 6 Residents denied the allegation. S1 denied the incident ever happened. R1 stated they do not remember the incident. Report continued on 9099c The investigation reveals the following: Regarding “Staff do not conduct group activities for residents'., it is alleged that facilities do not provide activities for the residents. The administrator and staff stated that they provide residents with activities such as puzzles, cards, dancing, music, the lottery, and spa treatments. 3 out of 6 residents stated the facility provides activities. 1 out of 6 residents stated there were no activities. 1 out of 6 residents stated there were activities but chose not to participate. 1 out of 6 residents is unsure if they did activities. LPA received/reviewed the activities calendar provided by the facility. Based on LPA's interviews, investigation revealed: Although the allegations 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 Administrator/ A Copy of the Report Issued. Prior to the visit, LPA interviewed Resident #1(R1) and staff#1(S1). LPA interviewed two family members of R1, a Hospice Nurse, a Cal Aim placement coordinator, and a Family friend of R1, who shall be referred to as W1 through W5. The investigation reveals the following: Regarding " Staff do not provide residents with adequate food service," it is alleged that R1 has lost significant weight over the past three months. The Administrator and staff stated that all residents eat 3 times a day with snacks in between. All 5 residents confirmed that they were provided with adequate food. LPA received pictures of R1's food from the administrator and family members. The food described in the photo was a sandwich and a bowl of shredded chicken. LPA reviewed R1’s physician’s report and confirmed R1 is on a puree texture, No Added Salt (NAS), and Consistent Carbohydrate (CCHO) diet. The food R1 was receiving did not align with the diet that was ordered by the physician. The investigation reveals the following: Regarding " Staff refused to accept the resident back to the facility," it is alleged that the facility refused to accept the resident back from the hospital. The Administrator stated they did not take the resident back because the resident requires blood sugar checks, and the facility is not equipped to manage their medication. The Administrator did not consult with Licensing nor follow the process for a resident needing a higher level of care. Based on LPA observations, interviews, and file review, the preponderance-of-the-evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC9099D. Exit Interview Conducted with Administrator/ Appeal Rights Provided / A Copy of the Report Issued.