complaint·October 15, 2025

Furthermore, the department conducted a tour of the facility and observed the residents to identify any signs of neglect, abuse or other immediate health and safety threats. On 12/12/24, the department conducted interviews with W1. On 12/13/24, the department conducted interviews with witness #2 (W2), S1. On 12/14/24, the department conducted interviews with W2. On 12/16/24, the department received Hospice Records from Valley Oaks Hospice, Inc. (dated: 12/01/24-12/16/24) for R1. On 12/19/24, the department received EMS records and 911 recording from Long Beach Fire Department. On 12/20/24, the department received the Death Certificate from R1 from Long Beach Department of Health and Human Services. On 12/24/24, the department conducted interviews with W2, and witness #3 (W3). On 12/26/24, the department conducted interviews with staff #2-#5 (S2-S5). On 12/17/24, the department conducted interviews with W1. On 12/31/24, the department conducted interviews with staff #6-S7 (S6-S7). On 01/06/25, the department conducted interviews with witness #4 (W4). On 01/07/25, the department conducted interviews with staff #8-#9 (S8-S9). On 01/09/25, the department conducted interviews with staff #10 (S10). On 01/13/25, the department received Home Health Records for R1 from Royal Majesty Home Care, Inc. On 01/14/25, the department conducted interviews with W1. On 01/15/25, the department received Medical Records from R1’s Gastroenterologist, SoCal Gastroenterology, Hospital Records from St. Mary Medical Center, and Medical Records from Provider 1st R1’s Primary Care Physician. On 01/28/25, the department conducted interviews with witness #5 (W5). On 01/31/25, the department conducted interviews with staff #11 (S11). On 02/03/25, the department conducted interviews with witness #6 (W6). On 02/04/25, the department conducted interviews with witness #7 (W7). On 02/06/25, the department conducted interviews with witness #8 (W8). On 02/10/25, the department conducted interviews with witness #9 (W9) and staff #12 (S12). On 02/11/25, the department conducted interviews with witness #10 (W10). On 02/12/25, the department conducted interviews with witness #11 (W11). On 02/14/25, the department conducted interviews with witness #12 (W12). On 02/19/25, the department conducted interviews with staff #13 (S13). On 02/21/25, the department conducted interviews with S1 and S4. On 02/25/25, the department conducted interviews with W1. On 02/28/25, the department conducted interviews with staff #14-#15 (S14-S15). On 03/07/25, the department received Imaging Records for R1 from St. Mary Medical Center. On 03/14/25, the department conducted interviews with W2. On 03/20/25, the department conducted interviews with witness #13 (W13). On 03/21/25, the department conducted interviews with witness #14-#15 (W14-W15). On 10/15/25, the department requested a copy of the staff roster, resident roster, and the facility menu. The department conducted interviews with staff #2 (S2), staff #16-#20 (S16-S20), and residents #2-#7 (R2- R7). The department was unable to interview R1, as R1 passed away. Furthermore, the department conducted a tour of the facility. The investigation revealed the following: For the a llegation: Staff did not provide adequate food service to residents in care. It is being alleged that the food is never cut up nor pureed for the residents that can’t manage a whole chicken breast or a sandwich they couldn’t hold. On 10/15/25, the department conducted interview with S2 and S16-S20. Of those interviewed, 6 out of 6 staff stated that residents are provided adequate food service based on their dietary needs or modified diets. 6 out of 6 staff stated there is enough caregivers to attend to residents during mealtimes. On 10/15/25, the department interviewed R2-R7, and were unable to interview R1, as they passed away. Of those interviewed, 6 out 6 residents denied the allegation. 6 out of 6 residents said they do not have a special diet, and they eat what they want. 6 out of 6 residents said that staff does cut up, and puree residents food. 6 out of 6 residents stated there is enough caregivers to attend to residents during mealtimes. During a review of records, the department observed two weeks of the facility menu. The menu offers a variety of meals throughout the day, such as breakfast, lunch, dinner, including protein, starch, vegetables, and fruits. A review the Staff Roster revealed that the facility has enough staff to meet the needs of the residents served. The department conducted a tour of the facility and observed residents consuming a balanced lunch, which included chicken noodle soup, with a side of fruit, juice, and water. The kitchen was inspected, during which the department observed a five-day supply of perishable food and a seven- day supply of nonperishable food items were noted. The kitchen appeared clean, and no health or safety concerns were observed during the visit. Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. 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 did not safeguard resident's personal items. It is being alleged that three sets of bedding and towels were purchased prior to a resident moving into the facility, yet there were never any towels, including hand towels to wipe their hands on, and only one sheet on the residents bed. On 10/15/25, the department conducted interview with S2 and S16-S20. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said they are not aware of a resident missing bedding and towels. 6 out of 6 staff said that the facility provides the residents with basic bedding necessities. On 10/15/25, the department interviewed R2-R7, and were unable to interview R1, as they passed away. Of those interviewed, 6 out of 6 residents said they haven’t had an issue with any of their belongings missing. 6 out of 6 residents said that the facility provides them with basic bedding necessities. During a review of records, the department observed that R1’s Resident Personal/Property and Valuables form (signed/dated: 04/27/23) was blank and had no personal items listed. Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. 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 did not meet residents' incontinence needs. It is being alleged that there is a lack of changing incontinence at the facility. On 10/15/25, the department conducted interview with S2 and S16-S20. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff stated that residents are checked on at least every two hour or as needed, and depending on their needs. 6 out of 6 staff said residents are not left in soiled briefs for an extended period of time. On 10/15/25, the department interviewed R2-R7, and were unable to interview R1, as they passed away. Of those interviewed, 6 out of 6 residents said they do not require any assistance with toileting. 6 out of 6 residents said that staff check on them frequently. 6 out of 6 residents said they have not observed a resident left in soiled briefs for an extended period of time. Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. 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. An exit interview was conducted, and a copy of the report was provided to Robert Jakini, Executive Director.