complaint·September 19, 2025

Allegation: Facility is in disrepair. It is alleged that both the refrigerator in the facility and garage have broken drawers making it difficult to open and take out ingredients, additionally its alleged that the air conditioner (AC) is not accessible to staff to turn on during the hot hours and it’s believed that the air conditioner does not work. LPA interviewed 4 staff and 3 out of 4 staff denied the above allegation. During initial visit dated 7/18/25 LPA observed air conditioner to be on and operable. During interviews with staff, it was revealed that the air conditioner is asked to be turned off between 6-8pm as residents complain of the facility being cold in the later evening hours. During initial visit LPA toured kitchen and observed kitchen refrigerator drawer to have a crack in center of the drawer area, opening and closing drawers was difficult as the crack makes the middle of the area bend inwards, creating a dip. During todays subsequent visit the kitchen refrigerator was still in disrepair with the crack in the middle of the bottom shelf making it difficult to open the drawers beneath it. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were emailed av528howardst@gmail.com . Allegation: Facility staff is not keeping Kitchen sanitary. It is alleged that the kitchen is not kept clean and dishes do not have a proper drying rack to dry dishes after washing, causing unsanitized dishes that will have an odor to them. During initial visit dated 7/18/25 LPA observed a dish rack on the kitchen counter that is used to dry dishes after washing. LPA interviewed 4 staff and 3 out of 4 staff denied the above allegation and stated that although the dishwasher is not utilized often, there is a removable drying rack on the counter that is used to dry dishes after washing. LPA interviewed 4 residents and each denied the allegation . LPA interviewed R1s responsible party and they denied the allegation stating that they have never observed dirty/unsanitary dishes, and on the times they are present for meals they haven’t observed any issues. LPA interviewed a hospice/home health nurse that services 5 residents at the facility and nurse denied the above allegation stating that during visits they sometimes assist their patients/residents with a glass of water or a snack and dishes have always appeared clean and sanitary. Allegation: Facility does not have enough staff to meet resident's needs. It is alleged that there is only one staff for 11 residents during the hours of 3pm-11pm, making it difficult for that one staff to perform all duties and ensure the safety of the residents. During initial visit there LPA observed 3 staff working in the facility on subsequent visit there were 2 staff working in the facility. LPA interviewed 4 staff and 3 out of 4 staff denied the above allegation and stated during morning, day, evening (until 7pm) there is always a minimum of 2 staff, during the night shift there is 1 staff as all residents are usually sleeping during those late hours. Interview with R1’s responsible party stated when they visit there is always at least 2 staff present, and staffing has never been a concern. LPA interviewed 4 residents and each denied the above allegation. LPA interviewed a hospice/home health nurse that services 5 residents at the facility and nurse denied the above allegation stating that during their visits there is always 2-3 staff available to assist the residents. Allegation: Facility is not kept free of pests. It is alleged that there are ants on the kitchen counters and residents bedrooms. During initial visit dated 7/18/25 LPA toured facility, kitchen, resident rooms and bathrooms were inspected and there were no signs of insects. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation. During interview with R1’s responsible party it was stated that they visit 4 times a week and have never observed ants/insects in the facility. LPA interviewed 4 residents and each denied the allegation. LPA interviewed a hospice/home health nurse that services 5 residents at the facility and denied the above allegation stating that they have never observed any insects/ants in the facility during their visits. (Continued on LIC9099-C) Allegation: Staff are not administering medication to residents as prescribed. It is alleged that the facility staff have administered medication to residents outside of time indicated on prescription. LPA conducted a medication review during the initial visit dated 7/18/25, LPA observed medication to be transferred out of their original container and staff were utilizing a weekly pill box, LPA also observed all original medication bottles for R1 to be missing from facility and it was explained that the family prefer to keep it at their home and provide facility with weekly medication pre-packaged boxes, this is against title 22 regulations and citations were issued during the initial visit on a case management visit. During medication review LPA reviewed medication lists, medication and medication administration records and did not find evidence that the facility is not administering the medication as prescribed. LPA interviewed 4 staff and 3 out of 4 staff denied the above allegation. LPA interviewed R1s responsible party and they stated that medication has not been an issue and believe staff are administering medication as prescribed. LPA interviewed 4 residents and each denied the allegation. LPA interviewed a hospice/home health nurse that services residents at the facility and they denied the above allegation stating that they have 5 patients they tend to once weekly and during the medication review they do not observe any errors. Based on statements and interviews conducted with staff/residents, facility tour and medication review, 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 was emailed