complaint·February 10, 2026

Facility submitted a copy of the resident roster and staff roster. LPA interviewed Administrator, Staff #2 (S2) to Staff #4 (S4), and Resident #1 (R1) to Resident #4 (R4) and Former Resident #1 (FR1). LPA was unable to interview Staff #1 (S1) due to language barrier. LPA reviewed and obtained documents from S1 to Staff #3 (S3’s) files that include: Staff Training and pertinent documents. LPA requested the monthly meal schedule and snack list. LPA toured the facility. LPA requested the Bed Repositioning Logs, Fire and Disaster Drill logs. On 02/06/2026, LPA spoke to the Administrator over the phone and obtained S4’s staff training documents. LPA also interviewed S4 over the phone. During today's visit, LPA obtained the following documents: staff and resident rosters. The investigation revealed the following: In regards to the allegation “Staff do not communicate effectively.” It is alleged that S1 and S2 cannot communicate with the residents at the facility because they do not speak English. LPA interviewed the Administrator and three (3) out of four (4) staff denied the allegation stating that the on-duty staff are able to communicate with the residents. LPA attempted to interview S1 but S1 was unable to communicate effectively or answer LPA’s questions due to the language barrier. Administrator stated that there is an on-call night shift supervisor and administrator available to speak with residents over the phone. However, these individuals are not physically present at the facility. However, per Administrator there are times when S1 is the only staff on-duty and not everyone living at the facility speaks S1’s language. This is a possible concern in case of an emergency there may be a language barrier between emergency medical personnel and S1 can have a language barrier. LPA interviewed one (1) out of four (4) residents that corroborated with the allegation stating that language barrier is a problem and sometimes there is one (1) staff at night that is unable to communicate with the resident in English. LPA interviewed an additional former resident that corroborated with the allegation stating that one (1) staff was unable to communicate in English. LPA interviewed three (3) out of four (4) residents that denied the allegation stating that the staff are able to communicate with the residents. There’s enough evidence to substantiate. Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. An exit interview was conducted with the Administrator, Diana Castellanos. A copy of the report and appeal rights were provided. Facility submitted a copy of the resident roster and staff roster. LPA interviewed Administrator, Staff #2 (S2) to Staff #4 (S4), and Resident #1 (R1) to Resident #4 (R4) and Former Resident #1 (FR1). LPA was unable to interview Staff #1 (S1) due to language barrier. LPA reviewed and obtained documents from S1 to Staff #3 (S3’s) files that include: Staff Training and pertinent documents. LPA requested the monthly meal schedule and snack list. LPA toured the facility. LPA requested the Bed Repositioning Logs, Fire and Disaster Drill logs. On 02/06/2026, LPA spoke to the Administrator over the phone and obtained S4’s staff training documents. LPA interviewed Staff #4 (S4) over the phone. During today's visit, LPA obtained the following documents: staff and resident rosters. The investigation revealed the following: In regards to the allegation: “Staff did not properly maintain floor surfaces.” It is alleged that the staff were more into cleaning than resident care and water was left on the floor during cleaning and not properly dried to prevent a fall risk. LPA interviewed the Administrator and three (3) out of four (4) staff that denied the allegation stating that they clean and properly dry the floor. LPA was unable to interview Staff #1 (S1) due to language barrier. LPA interviewed three (3) out of four (4) residents that denied the allegation stating that floors are kept clean, dry, and staff ensure that the residents are safe from falls after the floors are cleaned. LPA interviewed one (1) out of four (4) residents and one (1) former resident that corroborated with the allegation stating that the staff clean the floor often, which causes the floors to be kept wet and slippery and can cause a resident to fall. LPA toured the facility and observed the floors in th e kitchen, dining room, hallways, resident bedrooms, and bathrooms were all clean, dry, and not wet nor slippery. There is not enough evidence to substantiate. Allegation: “Staff spoke inappropriately towards the residents.” It is alleged that the staff were not talking to the residents with dignity, respect and love. It is also alleged that the residents are afraid to report due to fear of retaliation. LPA interviewed the Administrator and three (3) out of four (4) staff that denied the allegation stating that all staff speak with residents with respect, dignity, and love and have not witnessed any other staff speak to residents without respect, dignity, and love. LPA was unable to interview Staff #1 (S1) due to language barrier. LPA interviewed one (1) out of four (4) residents and one (1) former resident that stated that there are some staff that speak to them in a frustrated and unfriendly tone but stated that there are some staff that treat them in a pleasant manner. LPA interviewed three (3) out of four (4) residents that denied the allegation stating that they are treated by staff with dignity, respect, and love and have not been mistreated by staff. There is not enough evidence to substantiate. Allegation: “Staff did not provide adequate care and supervision.” It is alleged that facility staff are not conducting checks on bed bound residents. The residents are left to help themselves and the current residents need skilled care to provide resources. The Administrator, three (3) out of four (4) staff interviewed denied the allegation. LPA was unable to interview Staff #1 (S1) due to language barrier. LPA interviewed three (3) out of four (4) residents interviewed denied the allegation stating that their cares are met. LPA interviewed one (1) out of (4) residents and one (1) former resident that denied the allegation but both stated the wait time to be helped by staff took a long time as there were times when the wait time was at least thirty minutes. LPA reviewed the Repositioning/Diaper Change log in January 2026 that their bed bound resident was repositioned/changed every two hours. Based on staff and record review and interview, there are two (2) caregivers on duty per shift and one caregiver on duty in the noc shift. All residents indicated that there are sufficient staff available to help provide care and supervision to meet their needs. LPA observed at the facility that the residents were being closely supervised by the care staff and that there were no immediate health or safety concerns. LPA interviewed two (2) residents that are non-ambulatory stating that they are checked daily by staff. LPA reviewed S1 to S4’s file that included staff training on Resident Care and Supervision conducted on May 2025 and Incontinence Care/Prevention of Skin Breakdown conducted in June 2025. Therefore, there was insufficient evidence to corroborate with the allegations. Allegation: “Staff did not provide adequate food service” and “Staff do not ensure a resident is being properly fed.” It is alleged that residents lost a lot of weight due to the food portions were not sufficient and the diets did not contain protein items. It is also alleged that the facility had to do Uber Eats to get enough food due to the staff not providing snacks in between meals. It is alleged that the residents are not allowed to put their food in the refrigerator due to the kitchen being "closed" for the night. LPA interviewed the Administrator and three (3) out of four (4) staff and they all denied the allegation. LPA was unable to interview Staff #1 (S1) due to language barrier. All staff interviewed indicated that all residents at the facility receive three meals and three snacks per day. All staff interviewed also indicated that facility provides a sufficient amount of food to all of the residents in care. LPA interviewed three (3) out of four (4) residents all claim they get enough food from the facility staff. LPA interviewed one (1) out of four (4) residents and one (1) former resident that corroborated with the allegation stating that they are not satisfied with the food served and that residents have lost weight due to lack of variety, alternate choices, and protein. LPA observed four (4) residents eating their meal at the dining hall during lunch time from 12:05pm to 12:30pm. LPA observed the kitchen and have sufficient supply of 2-day perishable & 7-day non-perishable food. [Continue to LIC9099-C] Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. LPA observed eating the following items: Empanadas, potato pie, avocadoes, Jello, and beverage. Residents were in a pleasant mood while continuing to eat lunch. LPA observed no concerns regarding residents not getting enough food from the facility. LPA reviewed S1 to S3’s file that included staff training on Cultural Competency and Sensitivity conducted on September 2025. LPA reviewed S4’s file that included staff training on Cultural Competency and Sensitivity conducted on January 2025. There is not enough sufficient evidence to substantiate. Allegation: “Staff did not provide adequate lighting for the residents.” It is alleged that the home has no lights in the hallway and the staff would not assist when residents needed to get up at night to use the bathroom. LPA interviewed Administrator and three (3) out of four (4) staff that denied the allegation stating that adequate lighting is provided and they assist residents at night to use the restroom. LPA was unable to interview Staff #1 (S1) due to language barrier. LPA interviewed one (1) out of four (4) residents and one (1) former resident corroborated with the allegation stating that the hallway lights are not turned on at night by staff when residents need to go to the restroom. LPA interviewed three (3) out of four (4) residents that denied the allegation stating that there is adequate lighting all day and night so that staff can help provide assistance for residents to go to the restroom. LPA observed that hallway lights are on. Per Administrator, the hallway lights are on at night to assist residents to go to the restroom. There is not enough sufficient evidence to substantiate. Allegation: “Staff do not follow proper fire safety measures.” It is alleged that the facility does not have any fire extinguishers. LPA interviewed the Administrator, three (3) out of four (4) staff that denied the allegation stating that they are properly trained and conducted in fire drills. LPA was unable to interview Staff #1 (S1) due to language barrier. LPA interviewed one (1) out of four (4) residents that denied the allegation stating that the facility does have fire extinguishers in the facility. LPA interviewed three (3) out of four (4) residents who can confirm nor deny the allegation not knowing if the facility conducts fire safety procedures. LPA also observed two (2) fire extinguishers that are fully charged and last inspected on 09/04/2025. Carbon Monoxide detectors were tested and are operating properly. LPA reviewed prior Fire and Disaster drill logs and the Last Fire Drill was conducted on 11/12/2025. The Last Disaster Drill was conducted on 11/12/2025. LPA reviewed S1 to S3’s file that included staff training on Building and Fire Safety and Appropriate Emergencies Response conducted in October 2025. LPA reviewed S4’s file that included staff training on Building and Fire Safety and Appropriate Emergencies Response conducted in January 2025. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is vali d, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided to the Administrator, Diana Castellanos.