complaint·December 2, 2025

During interviews with the residents, three (3) out of five (5) interviewed did not corroborate the allegation. One resident interviewed stated that they recently required hospitalization, and that staff assisting them in obtaining medical care in a timely and prompt manner. Another resident interviewed stated that they staff have assisted them in an adequate time frame when they have required medical assistance. During interviews with staff, none of them corroborated the allegation. One of the staff interviewed stated that they became aware that R1 required medical attention on 11/23/2025 and contacted their hospice agency at around 11:00 PM to ask if they would be able to send a nurse to see the resident, however after an hour the hospice agency indicated they would not arrive until 8:00 AM on 11/24/2025, and at this time it was decided an ambulance would be called to take R1 to the hospital. Another staff interviewed also confirmed that a private ambulance was called at 11:00 PM per R1's request, and was sent to the hospital afterwards. Progress notes indicate that R1 was sent out to the hospital via private ambulance at 2:36 AM on 11/24/2025. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report along with appeal rights were provided to the administrator. During interviews with the residents, one (1) out of five (5) corroborated the allegation. One resident interviewed stated that they were hospitalized and that their family was not notified of the visit until the family had called the facility the following day. During interviews with the staff, none of them corroborated the allegation. S1 stated that S3 called the primary relative of R1 following the incident on 11/24/2025 at 2:00 AM, however they are unsure if the contact was reached. S3 stated that they attempted calling family relatives of R1, however the call went to voicemail, and they cannot recall if they ever called back. During record review before the visit, LPA observed that no serious incident reports (SIRs) have been submitted to Community Care Licensing Division (CCLD). An SIR was provided to LPA during the visit dated 12/2/2025, however this is eight (8) days after the occurrence of the incident, which exceeds the seven (7) day time-frame required per Title 22 regulations. Based on LPA interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED . California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D page. Exit interview was held and a copy of the report along with the appeal rights were provided.