complaint·November 13, 2025

The investigation, into the allegation, facility staff handle resident roughly when transferring causing pain, revealed the following. It was reported that when staff transfer Resident 1 (R1) they handle R1 in a rough manner that causes pain. Staff 1 and Staff 2 reported that R1 complains of pain when moving no matter how gently they assist. R1 reported that most movement causes them pain. The Administrator reported that no matter how slowly they assist or move R1 they complain of pain. The Home Health Nurse reported that R1 reports pain any time they are moved and assisted and they have observed staff and everything is being done to assist R1 in a safe comfortable manner. The Home Health Nurse reported that there doesn't seem to be a medical reason for the pain reported by R1 and they advised staff to be careful and gentle when moving R1. Based on the evidence gathered, the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation, into the allegation, resident developed a pressure injury while in care, revealed the following. Resident 1 (R1) moved into the facility December 16, 2023 and moved out of the facility on August 21, 2024. It was reported that R1 had a pressure injury that was caused by facility staff assisting R1 which caused them to remain in bed most of the time. R1 reported they enjoyed staying in watching TV. The Administrator reported they assist R1 into and out of bed every time they request it, R1 verified this report. Staff 1 and Staff 2 reported they always assist R1 into and out of bed when requested. The Home Health Nurse reported that R1 did have redness on the lower back but it never developed into a pressure injury and it was resolved. The Administrator reported that R1 had continuous Home Health visits for the duration of their stay. There is no record of R1 being diagnosed with a pressure injury. Based on the evidence gathered, the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility staff does assist residents with providing transportation for medical appointments, revealed the following. It was reported that the staff never have R1 ready to go to their medical appointments and when the transportation arrives R1 is not ready. Transportation cannot wait for R1 therefore they leave the facility and R1 ends up missing their appointment. Staff 1 and Staff 2 reported that R1 is always ready to go but R1's responsible party causes the delays and has changed the appointments at the last minute which has caused problems. The Administrator reported that R1 is always ready to go but R1's responsible party has caused issues by asking for R1's clothes or hair to be changed at the last minute, when R1 was already prepared to go. R1's responsible party denies the allegations. R1's responsible party reported that staff never have R1 ready to go but did not provide any specific details. R1 would not answer any questions regarding their missed appointments. LPA contacted the transportation driver but never received a response. Based on the conflicting information received, it can't be determined what actually transpired when R1 had medical appointments. Based on the evidence gathered, the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility staff do not perform proper hand hygiene while working, revealed the following. It was reported that the Administrator and Staff 1 (S1) do not regularly wash their hands after assisting residents. 1 out of 6 residents interviewed reported they never see the Administrator or S1 wash their hands. S1 and the Administrator denied the report and stated they wash their hands after assisting each resident. No specific details were provided as to dates and times or incidents when facility staff did not wash their hands. There is no evidence to support the allegation, therefore the allegation is unsubstantiated, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. The investigation into the allegation, facility does not provide residents with nutritious meals revealed the following. The facility has a posted menu in the kitchen, but the menu is not followed. The meals listed for March 18, 2024, were not followed. Residents and staff interviewed reported that on March 18, 2024, residents had cereal and milk for breakfast, no other items were mentioned. LPA observed ground beef tacos being served for dinner, but there was not side dish of a vegetable, rice or potatoes. The only item was the main entrée. To drink there was milk, water or soda. No dessert item was served. A variety of food must be served that meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. Breakfast and dinner did not have all the required food groups, and no fruits or vegetables were offered. Staff and residents interviewed reported that in between meal snacks were offered. Snacks offered were crackers and cookies. 3 out of 6 residents reported that water is always available. The preponderance of evidence standard has been met, therefore the allegation is substantiated. The investigation into the allegation, residents not afforded privacy when visiting with family, revealed the following. It was reported that during a visit with Resident 1 (R1) and their family the Administrator walked into the room unannounced and interrupted the visit. The incident was reported to have taken place on June 24, 2024. The Administrator reported that they did walk into R1’s room unannounced and had issues they needed to discuss with R1. The Administrator reported that they apologized and there have been no further incidents. R1 and W1 verified this information. The Administrator, R1 and W1 all reported the incident took place on June 24, 2024. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation is substantiated. The investigation into the allegation, facility is not clean and well maintained revealed the following. It was reported that the facility is in disrepair, and the facility has torn carpet in the living room, paint is chipping the kitchen and dining room, the kitchen cabinet doors are broken and the vanity in the bathroom in the hallway is broken. LPA observed during the initial 10-day visit all the items mentioned above need repair. The carpet is torn, the bathroom vanity is broken and has cracked wood, the kitchen cabinet doors need new hinges and don’t close properly and the paint in the kitchen and dining room is chipped. LPA observed the kitchen is not clean there was food debris on the kitchen counter and in the storage drawers. LPA observed the kitchen stove is not clean and has grease and dirt on it. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations, an exit interview was conducted and a copy of the report provided along with appeal rights.