Complaint·March 19, 2026

The investigation revealed the following: Regarding the allegation "Staff do not ensure accurate resident records are maintained", it is being alleged that a hospital has outdated information regarding the Power of Attorney (POA). Between 09:00AM and 12:30PM, LPA interviewed three (3) residents and three (3) staff. Record reviews revealed that there has been a change in a residents' choice of POA. However the updated POA is only valid with Veterans Affairs (VA) hospital and has not yet been notarized due to a resident's California State Identification (ID) being expired. This indicates that the updated POA paperwork is not yet valid at hospitals outside of the VA, which is where a resident was most recently taken. Interviews revealed that all three (3) clients and all three (3) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation " Staff did not provide medical personnel with medical records in a timely manner.", it is being alleged that, as of 03/16/26, an updated POA has not been provided to a dialysis treatment center. Record reviews revealed that there has been a change in a residents' choice of POA. However the updated POA is only valid with Veterans Affairs (VA) hospital and has not yet been notarized due to a resident's California State Identification (ID) being expired. This indicates that the updated POA paperwork is not yet valid at hospitals outside of the VA, which is where a resident was most recently taken for dialysis treatment. Interviews revealed that all three (3) clients and all three (3) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation " Staff are over medicating resident in care." Record reviews revealed that all medications being provided to a resident (R1) align with medications that have been ordered by R1's doctor and are being provided in a timely manner. Interviews revealed that all three (3) clients and all three (3) staff have denied the allegation has taken place. LPA's observation of R1's medication align with R1's MAR and there are no other medications, outside of R1's doctor's orders, being provided to R1. Based on record reviews, interviews conducted and LPA's observation, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Susana "Nadine" Sibayan - Assistant Administrator and a copy of this report has been provided.