complaint·March 3, 2026

Regarding: Staff did not ensure that resident had clean linen. It is alleged that resident’s bed was smeared with feces and was overall very dirty. Staff deny the allegation. Interviews with (5) out of (5) staff indicated that residents’ bedding is monitored for cleanliness by caregivers and housekeeping staff throughout each shift. Staff indicated that residents’ bedding is not left smeared with feces or other things which may soil the bedding. Staff indicated that full bedding changes are made twice a week during resident showers and that during a bedding change, mattress pads, sheets, pillowcases and blankets are removed and replaced with clean ones. Staff then place soiled bedding into clear bags and are labeled to ensure they get picked up and taken to get washed. Staff stated that if residents have accidents bedding is changed immediately. Staff indicated that the facility has sufficient bedding available for use. Interviews with (8) out of (8) residents revealed that they have everything they need and do not have concerns regarding their bedding. LPA inspected (10) rooms during visit and observed bedding to be clean and in good repair. Beds had mattress pads, fitted sheets and blankets. The facility has extra bedding on hand which is kept in a linen closet and bedding was observed being washed in the large laundry room. Staff and resident interviews and LPA observations do not corroborate the allegation that resident’s bed is smeared with feces and was overall dirty. Regarding: Staff did not ensure that resident's room was free of hazards. It is alleged that shattered glass and large shards were observed in resident’s room and still present covered only by a sheet from a broken glass door. Staff deny the allegation. Interviews with (5) out of (5) staff revealed that they have not observed shattered glass and large shards in residents’ rooms during their visits. S1 indicated that the glass on R1’s sliding door in their rooms was broken on 2/28/2026 due to R1 falling into the glass door while experiencing dizziness; however, maintenance staff were called in to pick up the broken glass immediately after the incident. Staff further indicated that when glass is observed on the floor or on the ground of the facility, it is reported to maintenance immediately and the area is secured to limit access while it gets cleaned up. LPA inspected R1’s room and did not observe shattered glass or large shards. LPA inspected (9) more resident rooms and did not observe broken glass, large shards or other hazards. Interviews with (8) out of (8) residents revealed that they have no concerns regarding their rooms. Staff and resident interviews and LPA observations do not corroborate the allegation that resident’s room was not free of hazards. **Continues on LIC 9099-C page 2** Regarding: Staff did not provide a safe environment for the resident. It is alleged that resident should not have been walking and require a wheelchair, but facility did not have one available for resident to use. It is also alleged that resident had to gain access into the facility through an unlocked side door due to staff not answering the phone in the front office to let resident in. Staff deny the allegation. Interview with S1 indicated that residents are provided with mobility assistance devices like wheelchairs, walkers and canes as ordered by doctors and when needed. S1 indicated that R1 was recently discharged from the hospital; however, hospital staff did not follow protocol by calling the facility to arrange resident’s return so that facility staff can have R1’s wheelchair readily available. S1 indicated that R1 received their wheelchair the same day R1 returned from the hospital after R1 was situated in their room. Interviews with (5) out of (5) staff indicated R1 was provided with their wheelchair upon arrival at the facility from the hospital. LPA interviewed R1 in their room and R1 confirmed that the wheelchair observed in R1’s room belonged to R1. LPA inspected the mobility equipment storage room and observed extra wheelchairs and walkers. Interviews with (8) out of (8) residents indicated that they have everything they need and have no concerns. S1 further indicated that hospital personnel who transport residents back to the facility after being discharged are provided with the front door pin number when arranging for a resident’s return to the facility. S1 stated that hospital personnel who brought R1 back from their hospital visit did not follow protocol and did not call facility staff to coordinate R1’s return by which they would have received the front door pin number to gain access. S1 indicated that receptionists end their day at 4:30 p.m. and therefore, the front office will be temporarily vacant if someone is called to conduct business away from the front desk. S1 indicated that if hospital personnel had called the facility first to coordinate the return of R1 to the facility, they would have been provided with the access pin number to let themselves in or have staff ready to receive R1. Interview with (5) out of (5) staff indicated that the side gate is left unlocked during business hours so that residents can leave the facility if they need to. Staff also indicated that the gate is locked in the evenings to ensure safety. Interviews with (8) out of (8) residents indicated that they feel safe at the facility. LPA observed the facility phones to be working properly during visit. Staff and resident interviews and LPA observations do not corroborate the allegation that staff do not provide resident with a safe environment. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated . An exit interview was conducted with Bryanna Luke, Administrator, and a copy of this report was provided. Regarding: Facility is in disrepair. It is alleged that a door in residents’ room is broken. It is also alleged that doorbell of the facility is not working. Interview with Staff 1 (S1) indicated that the glass on R1’s sliding door in their room was broken on 2/28/2026 due to R1 falling into the glass door while experiencing dizziness. S1 stated that maintenance staff were called in to pick up the broken glass immediately after the incident; however, the glass has not been replaced due to the facility waiting on the door to arrive and to be installed which had to be custom ordered. LPA inspected R1’s room and observed that the door is currently covered with cardboard through the inside and a plywood sheet on the outside. Interviews with (9) out of (10) residents indicated that there are no issues concerning their rooms; however, R1 acknowledged that the sliding door in R1’s room is broken. Interview with (5) out of (5) staff indicated that the sliding door in R1’s room has been broken since 2/28/2026; however, review of purchase invoice for the replacement sliding door indicates that the order was placed on 3/2/2026. LPA tested the doorbell of the facility’s main entrance door and found it to be operable. Further interviews with staff indicated that the doorbell is working and is heard when visitors push it. Interviews, observations and record review corroborate the allegation that door in resident’s room is broken. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated . California Code of Regulations (Title 22), is being cited on the attached LIC 9099-D. An exit interview was conducted with Bryanna Luke, Administrator, and a copy of this report was provided and Appeal Rights was provided.