complaint·January 30, 2026

The investigation revealed the following: Regarding: Staff are not ensuring that facility is clean and sanitary after meal services. Regarding: Staff are not ensuring that facility is clean and sanitary after meal services. It is alleged that staff are leaving food out on the tables when returning for lunch and dinner, not cleaning tables and chairs, sweeping floors and leaving food on walls when residents spill something. Interviews with (6) out of (11) staff who work directly in the kitchen and dining rooms indicated that the two resident dining rooms are cleaned before and after every meal service. Staff indicated that tables and chairs are cleaned and sanitized, floors are swept and mopped 2-3 times a day and spills are wiped down immediately. However, staff indicated that sometimes time is limited during cleaning and staff are unable to do more frequent cleaning of the walls and baseboards which have stains from drinks and food. Interview with S1 and S7 further indicated that walls, baseboards and some areas of the floors are hard to clean due dated surfaces. Interviews with (11) out of (12) residents indicated that they have no concerns regarding the dining rooms not being kept clean by staff. However, LPA inspection and observation of the two dining rooms during and after meal services revealed that several walls and baseboards have splattered stains from drinks and other food particles. LPA also observed dirt and grime stains around the corners of the floor by the grand piano and doorways in both dining rooms. Interviews with staff and LPA observation corroborate the allegation that staff are not ensuring that the facility is clean and sanitary after meal services. Regarding: Staff do not follow resident’s care plan. It is alleged that staff are not checking on resident every two hours as stated on their care plan. Interviews with (6) out of (11) staff revealed that residents who are “independent” and do not require incontinence care are checked on “frequently” during a work shift which is 7.5 hours a day. Staff indicated that residents get visits from staff three times per shift if they are considered independent and do not require incontinence care which would be noted on their Care Plan. Interview with S1-S3 indicated that R1 is now receiving “frequent” checks due to being “independent” and not needing incontinence care. Staff further indicated that “frequent” checks for R1 are a minimum of 2 checks, maximum 3 checks per shift. However, review of R1’s Care Plan in R1’s resident file indicated that R1 has “safety checks – 4 times per shift.” Further interviews with S1 and S2 indicated that no changes to R1’s current Care Plan have taken place and therefore, the Care Plan stands. *****Continues on LIC 9099-C page 2***** Interviews with (11) out of (12) residents indicated that their needs are being met by facility staff; however, staff interviews and record review corroborate the allegation that staff do not follow resident’s care plan. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated . California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.