complaint·June 28, 2025

The investigation revealed the following: Regarding allegation: Licensee does not ensure that staff are adequately trained. It is alleged staff do not receive initial training or yearly training. Interviews conducted with residents revealed 6 out of 6 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed training is provided prior starting to work at the facility. Documents reviewed revealed; administrator provided copies of training material via pictures. However, there were no training logs that record the date and time of yearly or initial training provided to staff #2(S2). Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding allegation: Licensee does not ensure that there is a designated substitute at the facility when the administrator is not at the facility . It is alleged administrator left on vacation in December 2024 and did not leave a responsible designee. Interviews conducted with residents revealed 6 out of 6 residents were unable to answer due to cognitive skills. Interviews conducted with staff revealed there is a designated person when the administrator is out. Per administrator, administrator took a vacation in December and left staff #3(S3) as the designee of responsibility and they should have submitted the Designation of Responsibility LIC 308 to the department. LPA reviewed documents submitted to the department between December 2024 and May 2025, there was no record of appointing S3 or other staff as the designee for responsibility. Administrator did not provide a copy of document submitted to the department with transmittal sheet. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Lakeisha Ogesby and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff members are not assisting residents with residents ADLs . It is alleged residents are not assisted with showers and changing their adult underwear. Interviews with residents revealed 4 out of 6 residents stated staff assist them with all activities of daily living. 2 out of 6 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed staff assist residents with changing adult underwear at least every two hours or as needed and provide showers to residents in care at least twice a week. Facility does not keep logs for showers or changing. 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. Regarding allegation: Staff member forces resident to stay in bed all day. It is alleged Resident # 1(R1) is left in bed all day without social interactions or friends. Interviews conducted with residents revealed 4 out of 6 residents stated to have activities throughout the day, staff provide care, and all residents have meals together. Interviews with staff revealed staff ensures all residents are brought to the dining and activities are provided throughout the day. During the visit conducted on 4/22/25 LPA observed all residents in the dining finishing breakfast. 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. Regarding allegation: Staff member falsified the facility MAR. It is alleged staff filled out the medication sheet without providing the medication. Interviews with residents revealed 6 out of 6 residents were unable to answer questions regarding medication due to cognitive skills. Interviews with staff revealed the staff is aware that the medication sheet (MAR) should be initial after providing the medication daily. During the visit LPA reviewed medication for 5 residents. LPA observed 3 out of 5 residents medications sheets were initialed for afternoon medication which had not been provided to residents yet. Although the facility staff made errors by initialing the MAR prior giving the medication, there is no proof that the staff is falsifying MAR sheets. Therefore, the allegation is unsubstantiated. 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. (continued on LIC9099-C) Regarding allegation: Licensee is not addressing resident’s fall risk. It is alleged that Resident # 2(R2) fell from bed several times and staff did not do anything about it. Interviews with residents revealed staff assist them as needed. Residents were unable to provide additional information regarding the allegation due to cognitive skills. Interviews with staff revealed there have not been falls among the residents within the last three months. There were no incident reports to note falls. On LPA Flores observed bed rails in R2’s bed. Although the incidents may have happened there is not enough evidence to support that the staff are not preventing residents from falling from their beds. 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. Regarding allegation: Administrator is not present at the facility a sufficient number of hours as required. It is alleged administrator is rarely at the facility. Interviews conducted with residents revealed 6 out of 6 residents were not able to answer question due to cognitive skills. Interviews with staff revealed administrator is present throughout the week. Per administrator, administrator visits the facility each day for a few hours, is involved during celebrations, special events that take place at the facility. 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. Regarding allegation: Staff did not report an incident involving a resident in care as necessary. It is alleged that resident #2(R2) fell while taking a shower. Residents were unable to provide information regarding this allegation due to cognitive skills. Administrator and staff stated there have not been falls sustained by the residents at the facility. Administrator stated there were no incidents to report to the department as there have not been falls. Document review did not reveal any incident reports submitted to the department for R2. 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. (continued on LIC9099-C) Regarding allegation: Licensee does not ensure that enough staff are present at the facility to meet the needs of the residents in care. It is alleged there is only one staff with the residents and additional staff is required as a resident with dementia wonders out to the street. Interviews with residents revealed there is staff to provide care to the residents, and their needs are being met. Interviews with staff revealed there is one staff per shift, which they believe it is sufficient as they are able to provide the care and meet the needs of the residents at the facility. Administrator stated that resident#3(R3) does tend to seek the exit. However, staff assist R3 by redirecting so R3 does not exit, and residents are not left alone. LPA observed the residents clean, dress, and care being provided at the time of the visit. Although the allegation may be true, per observation and interviews there is staff to provide care and supervision at this time. 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. Regarding allegation: Staff administered another resident’s medication to resident. It is alleged staff made a mistake and administered medication of a resident to another resident by staff. Interviews conducted with residents revealed 6 out of 6 residents were unable to provide information due to cognitive skills for this allegation. Interviews conducted with staff revealed there have not been any errors with medication that is being provided to residents in care. 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. Exit interview was conducted with Lakeisha Ogesby and a copy of this report was provided.