complaint·April 20, 2026

*** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** In regards of facility staff does not ensure contact information on filing a complaint is posted in the facility, it is alleged that the administrator will not provide R1 with the corporate office contact number or fax number to assist R1 in filing a complaint with the corporate office. P er resident interviews, one (1) out of ten (10) residents interviewed stated that the corporate office contact information for filing complaints is not provided. Nine (9) out of ten (10) residents could not corroborate with the allegation. It revealed that residents had resident meetings regarding any issues and those issues could be sent to the facility management and corporate office directly. In addition, Adult Protective Services (APS) poster with its contact information for filing complaints was posted on the wall at the lobby entrance if residents wanted to file complaints. Per staff interviews, seven (7) out of seven (7) staff interviewed could not corroborate with the allegation. Administrator would provide the corporate office’s contact information to residents when residents request it. Besides filing complaints to corporate office, Ombudsman’s and Licensing’s contact information for filing complaints were posted at the entrance and accessible to residents. Per observation, posters with contact information for filing complaints were displayed at the lobby entrance. Each poster was in size of 2.5ft (H) x 1.5ft (W) which residents could easily see them. Therefore, the contact information on filing complaints was accessible to residents. In regards of facility staff do not ensure residents care plan is being followed, it is alleged that R1’s care plan indicates staff are supposed to check on R1 every two (2) hours; however, staff neglect R1’s care and do not check on R1 every two (2) hours to ensure R1 is okay . Per resident interviews, one (1) out of ten (10) residents interviewed stated the staff did not follow resident’s care plan to check on resident every two (2) hours when providing care to the resident. Nine (9) out of ten (10) residents could not corroborate with the allegation. It revealed that residents receive care as stated on their care plan and as needed. Per staff interviews, seven (7) out of seven (7) staff interviewed could not corroborate with the allegation. (- continues on LIC 9099C -) *** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** The Administrator and staff stated they followed residents’ care plans when providing care assistance to residents. Per record review, R1’s care plan did not state R1 needed to be checked on every two (2) hours. R1 was ambulatory, living independently. Thus, staff follow residents’ care plans when providing care to residents. In regards of facility staff do not respond to call signal system for resident in care, it is alleged staff did not respond to residents’ calls while in care. Per resident interviews, four (4) out of ten (10) residents interviewed stated the staff did not respond to their calls on a timely basis. Six (6) out of ten (10) residents interviewed could not corroborate with the allegation. Residents stated staff responded to their call within 10 minutes. Per staff interview, all seven (7) staff interviewed could not corroborate with the allegation. The Administrator stated all call systems are working. As staff indicated, the front office would inform caregivers or housekeepers to go to a resident’s room when a resident presses the call button. Front offices use walkie talkies to communicate with staff. The respond time would not be more than five (5) minutes and staff would always respond to residents’ calls. LPA conducted a random signal system test during today’s visit. LPA tested the signal system in multiple rooms. Staff responded to the calls within a minute and staff arrived at the residents’ rooms in less than ten (10) minutes. Therefore, staff would respond to residents’ calls. In regards of facility staff do not ensure resident is spoken to in an appropriate manner, it is alleged that staff say to R1 inappropriately, such as calling R1 fat regarding R1's weight. Per resident interviews, two (2) out of ten (10) residents interviewed stated staff did not speak to them with a good manner. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed that staff were nice and show respect to the residents when speaking to them. Per staff interview, all seven (7) staff interviewed could not corroborate with the allegation. Staff treat residents with respect and dignity. Per observation, LPA observed residents in the hallway, dining room and activity room. Staff’s interaction with residents is friendly. Staff were nice to residents and residents looked happy when interacting with staff. (- continues on LIC 9099C -) *** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** Some residents would say hi to staff and staff would initiate a short conversation. Per record review, R1 had a history of fabricating stories. Therefore, there is not observed that staff are talking inappropriately to residents. In regards of facility staff does not ensure proper food service sanitation practices are followed, it is alleged that dietary staff did not wear hair nets and gloves while working in the dietary areas. Per resident interviews, two (2) out of ten (10) residents interviewed stated dietary staff did not wear hair nets and gloves. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed dietary staff were wearing hair nets and gloves when serving food. Per staff interviews, all seven (7) staff interviewed could not corroborate with the allegation. Staff stated that wearing hair nets, putting on gloves, washing hands and changing gloves were required all time. Staff were trained in proper food handling. All leftover food and refused food trays were disposed. Disciplinary action would be taken if staff did not follow the protocol. Per observation, kitchen looked clean, food was all covered, and staff wore hair nets/ gloves. Therefore, no sanitation issues in the kitchen were observed. In regards of facility staff served contaminated food to residents in care, it was alleged hair was found in residents’ food plates. Per resident interviews, two (2) out of ten (10) residents interviewed stated they found hair in their food plates. Eight (8) out of ten (10) residents interviewed could not corroborate with the allegation. It revealed residents did not observe their food was contaminated. Per staff interview, all staff have not heard of any residents having hair in their food. Staff are required to wear hair nets. Per observation, dietary staff wear hairnets while working in the kitchen and serving food. Per record review, a communication note reported that the hair that was found in the food plate was placed by residents, not from the kitchen staff. Therefore, residents’ food was not observed to be contaminated. (- continues on LIC 9099C -) *** This report supersedes the report dated 04/03/26. The superseded report was created to deliver a clarification of the allegations. The findings remain unchanged. *** Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Jacqueline Cortez, administrator. The findings were discussed and a copy of this report was provided.