Complaint·October 15, 2025

The investigation revealed the following: Regarding the allegation, “Staff are not providing resident with enough food to meet resident's needs”, it has been alleged that a resident is not provided enough protein in their daily diet. On 05/21/25, at around 09:30AM toured the facility’s kitchen and observed three (3) residents’ special dietary orders (R2-R4), located on the cork board as LPA entered the kitchen. At around 1:00PM, LPA collected four residents’ (R1-R4) dietary orders. Upon review of four residents’ dietary orders (DO), R1’s physicians’ DO does not mention any increase in protein for R1. During an interview with R1, R1 mentions that he is provided with about one and a half (1.5) chicken breasts, instead of three (3) chicken breasts as requested. Interviews revealed that three (3) out of four (4) residents and seven (7) out seven (7) staff have not agreed with this allegation. Based on LPA’s observation, 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 safeguard resident's belongings”, it is being alleged that nine (9) residents’ underwear have not been returned after being provided to housekeeper(s). On 05/21/25, at around 1:00PM, LPA requested any documentation of residents’ concerns regarding their personal belongings. LPA reviewed a residents’ safeguard of personal belongings, in which does not mention nine (9) pair of underwear. Interviews revealed that three (3) out of seven (7) residents and seven (7) out seven (7) staff have not agreed with this allegation. Based on LPA’s observation, 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. Report continues, please see LIC9099C. Regarding the allegation, “Staff do not answer residents calls for assistance timely”, it is being alleged that a resident must wait about one (1) hour to have their incontinence supply changed. At around 1:00PM, LPA reviewed a residents’ “caretrack” regarding toileting provided to a resident. According to caretrack, a resident was provided toileting assistance at 9:00PM and at 11:00PM, 01:00AM, 03:00AM and at 05:00AM. Interviews revealed that six (6) out of seven (7) residents and seven (7) out of seven (7) staff have denied the allegation has taken place. Based on LPA’s 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 administer resident's meds timely causing resident to miss medications”, it is being alleged that a residents’ cream was not administered on the date of 05/08/25. At around 1:00PM, LPA reviewed a residents’ caretrack. On 05/08/25, caretrack notes the cream mentioned as having been provided at the following times: 08:00AM, 12:00PM and 5:00PM. Interviews have revealed that five (5) out of seven (7) residents and seven (7) out of seven (7) staff have denied the allegation has taken place. Based on LPA’s 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. There has been one deficiency cited during today's visit, please see LIC9099D. An exit interview was held with Vanita Harris - Business Office Manager and a copy of this report has been provided. Regarding the allegation, “Staff are not following resident's special diet order”, it is being alleged that the facility is not following a residents' physician diet order. On 05/21/25, at around 09:30AM, LPA toured the facility’s kitchen and observed three (3) residents’ special dietary orders (R2-R4), located on the cork board as LPA entered the kitchen. R1’s diet was not observed. At around 1:00PM, LPA collected four residents’ (R1-R4) dietary orders (DO). R1’s special diet was created by their physician on 04/30/25, yet was not posted as other residents’ (R2-R4) DO was. Interviews revealed that four (4) out of seven (7) residents have agreed that the allegation has taken place. Based on LPA’s observation, record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. Please see LIC9099D. One deficiency was cited during today's visit, please see LIC9099D. An exit interview was conducted with Vanita Harris - Business office manager (S5) , and a copy of facilities’ appeal rights and this report has been provided.