complaint·April 16, 2026

Allegation: Staff prevents residents from using the public restroom by locking the doors. The complaint alleges that in early July 2025 the community/public 1st floor restroom was being locked so that staff had less of restroom assignments because at that time there was only one housekeeper in the building. It is alleged that a resident informed staff that the 1st floor restroom was locked, the resident was told to go upstairs to use the restroom in their room, and the inaccessibility and closure of the 1st floor public restroom caused the resident to have a couple of incontinence accidents on two different occasions. A total of 11 residents were interviewed. Seven (7) out of 11 residents confirmed the allegation. Resident interviews revealed that they were told by staff the 1st floor restroom was locked because residents were falling in the restroom. Residents said that some residents had incontinence accidents because they were not allowed to use the 1st floor restroom. The restroom closure affected residents in care and their visitors. A total of 13 staff were interviewed. Staff acknowledged the 1st floor restroom was locked and inaccessible to residents in order to "prevent injury". Staff interviews revealed that in early July 2025 Executive Director and medication technicians ordered housekeepers to keep the 1st floor restroom locked because a resident fell twice in the 1st floor restroom. Staff said that previous to the restroom closure directive, the restroom was only closed during maintenance or cleaning. It was established that residents who were able to to to the restroom on their own may be given access to the public restroom, and those that required incontinence assistance were to be escorted by staff to their room bathroom. According to interviews, there were several residents that had incontinence accidents because they did not get to their room bathroom in time. Staff interviews revealed that residents and visitors did not have access to the 1st floor public restroom without getting the key from the lobby receptionist. The findings revealed that the day receptionist shift is not 24 hours a day, and once their shift was over, there was no staff at the front to give residents access to the 1st floor public restroom. Allegation: Staff did not provide residents meal in a timely manner. It is alleged that in July 2025 meals were not being served on time and on July 16, 2025, lunch service was served at 12:38 PM, instead of 12:00 PM, and as a result residents and their families made attempts to reach out to Administration staff about the late meals, but they did not receive a response. A total of thirteen (13) staff were interviewed, of which nine (9) staff acknowledged that meals have been served late due to staff shortages. Staff interviews revealed that there was one occasion in which the lunch meal was served very late, close to 1 hour after the regular lunch time of 12 PM. The Dining Service Director confirmed that in the month of July 2025 meals were not being served on time because they were not familiar with the schedule since they had just began working at the facility on June 26, 2025. All kitchen staff interviewed confirmed the allegation and stated that on days where there are staffing shortages meals may be served late. For instance, during Summer 2025 there were kitchen/dietary aide staff shortages and at times there was only 1 or 2 dietary aides. According to staff, there are supposed to be 2 cooks and four aides per shift. Additionally, a new directive from Administration and Dining Services Director instructed kitchen staff to take meal trays to resident rooms, and previous practice had caregivers take the meal trays to the resident rooms. A total of 11 residents were interviewed, of which 8 confirmed the allegation. They stated that meals were being served late and cold during July 2025 because there was staffing shortages. Residents stated that meal serving times were not being followed because lunch service is supposed to be at 12:00 PM and during several weeks in July 2025 lunch and sometimes dinner meals were served approximately 30 minutes late but staff still wanted residents to be in the dining room by 12 PM and 5 PM despite meal service delays. The findings indicate that in 2025 there were changes to the Dining Services Director position that resulted in meal time and staff shortages. There is sufficient information to support the allegation. Allegation: Facility does not have a full-time Activity Director. It was reported that the facility did not have a full-time Activity Director for "a long time". In July 2025, the facility Activity Assistant went on leave and as a result there were limited or no resident engagement activities. According to 13 staff interviews, the facility did not have an Activity Director since the end of 2024 through October 2025. A staff member was appointed the Activities Assistant position in 2024, but went on leave in July 2025. As a result, there were no formal resident engagement activities like., exercise classes, bingo, arts and crafts, music programming, tea with friends, and board games. Receptionists were instructed to place coloring pages in the common areas as "independent activities" for residents. Weekend receptionists make popcorn & lemonade. During the initial complaint visit (7/22/25), LPA reviewed the weekly and monthly activities calendar. On 7/22/25, arts and crafts, manicures, bingo, nostalgic movies, ice cream/milk shake, and cocktail music was scheduled, but no activities were observed during the visit. A total of 11 residents were interviewed, of which 8 residents stated that there has not been an Activity Director "in a very long time" and the Activity Assistant was off on leave. Residents said there was no activity calendar posted and LPA confirmed during the visit that there was no activity calendar posted. Therefore, there is sufficient information to support the allegation. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Pursuant to Title 22, California Code of Regulations, a deficiencies are cited. An exit interview conducted, copy of the report and appeal rights was provided to Executive Director Colleen Rozatti.