complaint·November 13, 2025

Regarding the allegation that staff did not ensure the facility grounds are properly maintained: it was alleged that the facility’s roof leaked and was damaged during recent rain. LPA inspected the facility and observed that the roof had recently leaked and that several ceiling tiles were damaged, missing, and/or stained in the first floor dining room and adjacent hallway. AD stated that no residents were present when some ceiling tiles had fallen down in the dining room, no leaks were present in any resident rooms, and the facility took measures to address the water damage and to limit the damage during future rain. LPA interviewed 10 residents, none of whom reported additional physical plant issues at the facility. LPA observed ceiling stains in one of these residents’ rooms and also that the bathroom of another resident had leaked during the recent rain. The facility has previously had multiple issues with its leaking roof, including substantial leaks in early 2025 in the same locations as the current leak, and AD admitted that the facility still has not begun a full roof repair and is instead taking temporary measures of placing a tarp over the damaged roof which has not worked to prevent the leaks. Based on the information obtained, the facility has not taken sufficient measures to repair its roof after multiple leaks resulting in continued leaks damaging the first floor and posing a potential slipping risk for residents during rainy days. Regarding the allegation that staff did not keep the facility free from mold: it was alleged that after a recent roof leak, stains on the ceiling and smells in the hallway indicate there may possibly be mold. LPA inspected the facility and observed that the roof had recently leaked and that several ceiling tiles were damaged, missing, and/or stained in the first floor dining room and adjacent hallway. LPA observed ceiling stains in one resident’s room and also that the bathroom of another resident had leaked during the recent rain. In addition to the stains on the ceiling tiles, much of the water damage is deep in the ceiling and could not be seen. During the inspection, a City of La Habra code enforcement official required mold testing based on their observations of the water damage. However, although the leak occurred weeks ago, facility staff stated they still had not tested for mold, meaning the facility did not take proper steps to ensure the facility was free from mold in light of conditions that present the risk for mold. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that the facility is frequently short staffed, and in some instances in late October 2025 there were no caregivers or supervisors on duty. LPA interviewed AD who denied the allegation, stating that two caregivers resigned without notice recently but that the facility’s management team stepped in to cover. LPA interviewed WD who stated that the facility’s assisted living staffing schedule is for three or four caregivers plus one medication technician for the morning and afternoon shifts, with the memory care unit having its own separate set of three or four caregivers plus one medication technician for these shifts, and that during the overnight shift both the assisted living section and memory care unit share a set of three or four staff at least one of whom is a medication technician. Per WD, there were some recent call outs in assisted living and WD tried to get coverage for the call outs and covered some shifts themselves. LPA reviewed the facility’s timesheets for late October 2025 and confirmed that the facility’s staff levels were generally consistent with their staff schedule, although they did dip slightly low during certain afternoon shifts. However, per AD, even during these slight dips, the staffing level was above the facility’s minimum staffing requirement. LPA interviewed 10 residents and only one resident corroborated the allegation, stating that wait times for the call system could get very long, while the rest of the residents did not corroborate the allegation. Review of the facility’s recent call system logs, which includes dozens of calls, shows most calls are resolved within five or 10 minutes, although two calls took a little over 40 minutes. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.