Complaint·January 21, 2026

CONTINUED FROM FORM LIC9099-A During the August 2022 visit, licensing staff requested the laundry log for resident R1. A copy of the billed laundry service was provided during the visit. Regarding the allegation that Facility staff did not notify resident's authorized representative of a change in the resident's condition , the following has been concluded: Based on interviews and records reviewed during the investigation, no evidence was found that facility staff had knowledge of a change in R1's dental health prior to multiple broken teeth were found by R1's dentist on June 21, 2021 and surgically extracted on June 29, 2021. The dental care was scheduled and arranged by R1's responsible party, therefore the responsible party gained knowledge of the condition before facility staff did. Regarding the allegation that Facility staff did not ensure that resident had clean clothing , the following has been concluded: a laundry log and billing record for R1 shows 22 individual occurrences of laundry services being provided and billed to the resident's responsible party between the resident's admission in March 2020 and the resident's passing in January 2022. Interviews with facility housekeeping staff determined that initial clarification of the distinction between the linen service and personal laundry had been discussed with R1's family and that the resident regularly declined the service being provided on scheduled laundry days as R1 had already chosen to handle laundry themselves. Regarding the allegation that Resident was given a medical test without a doctor's order , the following has been concluded: the allegation was filed with the Department while the Coronavirus Disease 2019 (Covid-19) State Of Emergency had been declared . As part of the emergency declaration, facilities were operating under a waiver authorizing the use of PCR or antigen testing by facility staff for screening and isolation purposes. Additionally, R1's consent for emergency medical treatment LIC627 was signed by R1's responsible party in June 2019 and copied for the investigation file. No individual doctor's orders were required for testing at the time of the complaint. Regarding the allegation that Facility did not allow resident to use the pharmacy of their choice , the following has been concluded: Based on interviews conducted with staff, it was determined that residents are being provided the option to utilize the facility's preferred pharmacy provider but that individual choice to go through a different provider was possible as well. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Per a review of R1's resident records, medication orders dated April 18, 2020 made after the resident was admitted in 2019 show that prescription orders were sent to a CVS location in Orange rather than Guardian which was the preferred provider at the time, thus corroborating that the resident was free to go through a different pharmacy. Regarding the allegation that Facility is charging resident for services that are not in the Admissions Agreement , the following has been concluded: During the investigation of complaint reference 22-AS-20220211164547, the allegation that staff overcharged resident R1 was substantiated after it was determined that tray service had been charged in spit of a temporary suspension due to the coronavirus pandemic. However, the services for which charges have been disputed such as tray service and personal laundry were verified to be listed on Appendix C of the facility's admission agreement. Regarding the allegation that Facility staff is misappropriating facility funds , the following has been concluded: Following a change of facility management, records for the acquisition of religious decorations affixed to each resident's door could not be obtained. However, no actual evidence of misappropriation was provided during the complaint's investigation to corroborate the allegation. As a result, all six allegations mentioned above are determined to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility staff did not notice a change in the residents condition , the following has been concluded: Based on a review of medical records and charting notes, it is confirmed that upon admission R1 was on a regular diet. No issues with the resident dental health are documented in R1's charting notes prior to four broken teeth being extracted in June 2021, after which R1 was moved to a soft mechanical diet. It is therefore confirmed that the change in the resident's dental condition was not observed by staff in a timely manner. Regarding the allegation that Facility staff did not dispense resident's medication as prescribed , the following has already been concluded as part of the investigation of complaint " A review of the records and interviews concluded that the condition of Resident 1 (R1) was re-assessed by their primary care physician to have evolved to require assistance in the time period between yearly evaluations dated June 20, 2019 and August 20, 2020. The initial report indicates that the resident is noted as being able to self-administer their medication without supervision. The following physician report indicates however that the resident is no longer able to self-administer without supervision. Despite this change in condition, the resident was not transitioned to medication management status by the facility and formally assisted by facility staff until December 11, 2021 as documented in staff interviews as well as in printouts from the Medication Administration Records provided by the facility. (...) These elements confirm that the resident was left to manage her own medication with no formal assistance by the facility for a period of 16 months after a transition to Medication Management was ordered by the physician ". A deficiency for the same resident and circumstances was already cited on January 18, 2023 and is therefore not issued a second time. Based on the evidence gathered during the investigation, the two allegations listed above are deemed to be substantiated, meaning that the preponderance of evidence standard has been met. One cited deficiency per Title 22 Division 6 of the California Code of Regulations is detailed in the attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.