complaint·March 10, 2026

Continued from LIC9099 A... However, the facility provided resident’s records review, where there was an entry date 1/19/26 at 2:09pm indicates that R1 reported to staff (S1, S2 & S3) the alleged “abuse”, but the facility did not follow up on it. Also, on 12/12/25 there was another incident involving another resident (R2) where it was reported to facility management that staff (S4) was no longer welcome to care for R2 due to their incompetency when providing care and been always in a rush, getting defensive and other complaints that other staff raised about them, which resulted in management conducted an internal investigation and provided a written warning. LPA reviewed incident reports submitted to the Department and there were no incident reports regarding any of these reports. LPA will address in case management deficiencies discovered. A finding that the complaint allegation occurs of sexual assault is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Another allegation of Personal Rights was received. Per Reporting Party, the facility staff withheld R1’s phone and refused to allow them to use the facility phone. On 1/26/26 and 2/27/26, LPA conducted 10-day visit and subsequent visit to investigate this allegation. Based on LPA’s interviews conducted with staff (S5 & S6) and residents (R1, R2 & R3) in care who are residents that carry their own cellphone with them stated that they maintain their devices handy and expressed that staff help them when they are unable to make a phone call, but there were no concerns regarding refusal to allow them to use the facility phone. Although staff interviewed revealed that residents have a history of dialing 911 constantly for non-emergency reasons. Based on records review, LPA requested service calls from Mill Valley Police Department for the month of December 2025, and January 2026 confirmed assistance provided by medical agencies needed and couple of wellness checks conducted on 12/24/25 and 12/26/25, but no areas of concern were determined after visits. Based on LPA’s observations during interviews conducted with R1, R2 & R3, they were able to locate their phones in their pockets or their drawers located next to their beds. Based on LPA’s observations, interviews and records review there was no supporting evidence to indicate that the violation could have happened at a prior date. A finding that the complaint allegation occurs of personal rights is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued from LIC9099... Based on records review, R1’s physician report dated 12/23/25 and care plan address the need for a special diet due to glucose control needed, confirms that R1 is unable to perform own glucose testing. As of today, the facility did not follow up with R1’s physician or home health to obtain glucose check order and R1 has not been monitored their glucose levels since they were admitted back on 12/24/25. 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, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.