Complaint·January 8, 2026

The investigation revealed the following: Allegation: Staff allows resident to be left in soiled clothing for extended periods of time. It is being alleged that R1 was observed with filthy and soiled clothing. It is also being alleged that R1 only has one pair of underwear. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said residents receive a change of clothing daily and as needed. 4 out of 4 staff said that resident who require incontinence care are changed every 2 hours, and as needed. 4 out of 4 staff said that R1 has more than one pair of underwear. On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said staff had never left them in soiled clothing for an extended period of time. 6 out of 6 residents said they receive a change of clothing daily. 6 out of 6 residents said they own more than one pair of underwear. On 09/03/25, LPA Gonzalez conducted a tour of the facility and inspected R1’s bedroom (#118). LPA observed the room to be clean, sanitary, and in good order. LPA observed clean clothing stored in R1’s drawer space, including more than one pair of clean underwear available for R1’s use. Based on records reviewed, observation, and interviews conducted, there is insufficient evidence to support the allegation. 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: Resident sustained unexplained bruises. It is being alleged that R1 had red and purple bruises all over their arms and was walking in pain. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said that R1 has not sustained any unexplained injuries or unwitnessed falls. An interview with S1 revealed that they believe the spots on R1 are more like aging spots and not bruises. Continued on LIC9099-C On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said they have not sustained any unexplained injuries or unwitnessed falls. An interview with R1 revealed that they have never been physically abused at the facility, and that they don’t believe they have bruises on their arms, but rather more like aging spots. Additionally, on 09/03/25, while speaking with R1, LPA did not observe R1 to have any red and/or purple bruises all over their arms. Based on records reviewed, observation, and interviews conducted, there is insufficient evidence to support the allegation. 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 do not ensure resident receives adequate bathing services. It is being alleged that R1 only receives a bath once a week. It is also being alleged that staff never fully wash R1, causing a buildup of feces on their bottom. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said that residents receive 2 showers a week. An interview with S2 revealed that S2 is responsible for assisting R1 with bathing. S2 stated that R1 is scheduled to receive two showers per week; however, R1 often declines bathing, and during those times may receive only one shower per week. On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. 6 out of 6 residents said they bathe 2-3 times a week. An interview with R1 revealed that staff offer to assist them with bathing several times a week, but they chose to only bathe once a week. R1 said staff do a good job in assisting them with bathing, and that denied staff leaving buildup feces in their bottom. During a review of records, LPA reviewed caregiver notes and observed documentation indicating that R1 refused to shower on 07/02/25, 07/18/25, 07/30/25, and 08/08/25. LPA also reviewed the facility’s Bath Schedule, which indicated that all residents are scheduled to receive at least two showers per week. Based on records reviewed, observation, and interviews conducted, there is insufficient evidence to support the allegation. 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 does not ensure resident is free of mal odors. It is being alleged that a resident smelled very bad. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. An interview with S1 revealed that when staff observe an odor indicating a resident may require hygiene assistance, staff will request that the resident shower and change their clothing. On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. Additionally, on 09/03/25, while speaking with R1, LPA observed that R1 was wearing clean clothing and did not observe any odors emanating from R1. Based on records reviewed, observation, and interviews conducted, there is insufficient evidence to support the allegation. 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 do not observe changes in residents health care needs. It is being alleged that R1 could barely walk but did not have a cane or a walker for support. On 09/03/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff stated that R1 has not sustained any unexplained injuries or unwitnessed falls. 4 out of 4 staff stated that R1 has not complained about having any pain. 4 out of 4 staff stated that R1 is ambulatory. 4 out of 4 staff stated that R1 refuses to use a walker. On 09/03/25, LPA Gonzalez conducted an interview with R1. On 10/16/25, LPA Gonzalez conducted interviews with R2-R6. Of those interviewed, 6 out of 6 residents could not corroborate with the allegation. An interview with R1 revealed that R1 does not require the use of a walker and stated that they do not wish to use one. R1 reported that both their physical therapist and physician have recommended the use of a walker; however, R1 declined to use the device. Additionally, on 09/03/25, while speaking with R1, LPA observed R1 ambulating independently without the use of an assistive device. Continued on LIC9099-C During a review of records, LPA reviewed R1’s Physician’s Report (dated: 01/20/25), which indicated that R1 is ambulatory and does not require the use of an assisted device. Based on records reviewed, observation, and interviews conducted, there is insufficient evidence to support the allegation. 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. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Assistant Administrator Cecilia Torres.