complaint·July 31, 2025

Regarding the allegation that facility staff do not treat resident with dignity or respect: it was alleged that Staff #1 (S1) treats residents with disrespect. When interviewed, COO who stated that S1 was liked by some residents but unliked by other residents and that S1 no longer works at the facility. When interviewed, S1 stated they have a friendly, respectful, and jovial relationship with residents. One staff stated that S1 had a lot of issues with residents. Out of 12 residents interviewed, four residents corroborated the allegation and identified instances of rudeness, mockery, and ignoring resident inquiries by S1, Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4). The information obtained corroborated the allegation. Regarding the allegation that facility staff yells at residents in care: it was alleged that S1 yells at residents. When interviewed, COO who stated that S1 was liked by some residents but unliked by other residents and that S1 no longer works at the facility. When interviewed, S1 denied yelling at residents. One staff stated they have observed yelling between residents and staff and that S1 had a lot of issues with residents. Another staff stated that the PM shift has less positive interactions with residents because they are lower staffed. Out of 13 residents interviewed, two residents corroborated that S1 yelled at residents and in at least once instance got into a shouting match with a resident. The information obtained corroborated the allegation. 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. Regarding the allegation that facility staff are not ensuring that the facility is being adequately cleaned and sanitized: it was alleged that a mess was observed, staff did not respond to clean it up timely, and when staff did respond they cleaned it improperly. LPA Haddad inspected the entire facility, including hallways, common bathrooms, 10 resident rooms, and 10 private resident bathrooms, and did not obtain information corroborating the allegation. When interviewed, COO denied the allegation, stating that the facility is cleaned and sanitized. Three housekeeping staff interviewed denied the allegation and stated that the facility is regularly cleaned and when a mess is reported they will respond quickly to properly clean it up. Out of 12 residents interviewed, eight stated the facility was clean enough. Four of the residents interviewed stated the facility could be cleaner, but did not corroborate that cleanliness is a major concern for residents. One resident stated that when they identify a mess, they bring it up and staff will address it quickly. Although messes may occur within the facility, the information obtained did not corroborate that the facility is not regularly cleaning the facility and addressing messes in a reasonable time when they occur. Regarding the allegation that facility staff are not ensuring that restrooms are with toiletry supplies: it was alleged that resident bathrooms frequently lack basic supplies such as soap, toilet paper, and paper towels. LPA Haddad inspected the facility, including the common bathrooms and 10 private resident bathrooms, and did not obtain information corroborating the allegation. When interviewed, COO denied the allegation, stating that each resident receives two rolls of toilet paper every day, residents are welcome to ask for more, and that sometimes residents take toiletry supplies from the common bathrooms, but these are checked multiple times a day to ensure they are always stocked. Three housekeeping staff interviewed denied the allegation, stating that the common bathrooms are regularly restocked and that individual resident bathrooms are stocked based on the needs of the residents. For example, toiletry supplies may be given to the resident themselves instead of being stocked in their bathroom if there is a risk another resident may take the supplies or the supplies pose a risk to nearby residents. However, one staff did note that residents have been complaining about low stock of toiletry supplies in the common bathrooms recently. Out of 13 residents interviewed, 11 residents identified no issues with toiletries at the facility. Two residents stated that the common restrooms lack toiletry items once in a while. While some residents may have seen the common restrooms lacking toiletry items on occasion between restocking, LPA observed the facility has a sufficient supply of toiletries and no information was obtained that the facility is not regularly restocking toiletry supplies or that the facility is refusing to restock the bathrooms if notified of a shortage. The information obtained is conflicting. Regarding the allegation that facility staff are not adequately assisting residents with their needs: it was alleged that a resident was not properly assisted by S1 when S1 was pushing the resident in a wheelchair in the dining room and the resident’s foot became stuck but no injuries were sustained. LPA Haddad inspected the facility and observed multiple residents being transported in wheelchairs to and from the dining room by staff with no issues. The residents appeared comfortable in their wheelchairs, both during transport and while enjoying their meals, and the staff were attentive. When interviewed, COO stated that S1 no longer works at the facility and that the alleged incident, if it occurred, did not result in injuries. When interviewed, S1 was unable to provide information regarding the alleged incident, but stated they provide care to residents and have good relationships with residents. The resident at issue could not be interviewed because they have since passed away. Out of 13 residents interviewed, no residents reported issues with the care they received, staff responsiveness to their needs, or the quality of care. LPA reviewed S1’s staff training and noted it to be up to date for 2025. While S1 may have improperly transported a resident in a wheelchair during this instance, the information obtained did not corroborate any systematic issues with the care provided to residents in wheelchairs. Regarding the allegation that facility staff did not provide adequate food service to residents in care: it was alleged that S1 brings a resident late to meals, leaves the resident unattended despite the resident needing help with eating, and in one instance this resident was not served food timely. LPA Haddad inspected the facility and observed during meal times that residents in the dining room promptly received their meals and were eating without issue, there were three care staff as well as multiple kitchen staff serving food and assisting residents, and the residents were timely returned to their rooms after finishing their meals. LPA Haddad’s observations did not corroborate the allegation. When interviewed, COO stated that S1 no longer works at the facility. When interviewed, S1 was unable to provide information regarding the alleged incident, but stated they provide care to residents and have good relationships with residents. The resident at issue could not be interviewed because they have since passed away. Out of 10 residents interviewed, eight reported no issues with food service. However, two residents reported that they are sometimes late to meals because they are sleeping and staff do not wake them up. When interviewed, COO stated that as a general rule, staff do not wake sleeping residents because that is what most residents want and that residents who show up to the dining room late will still receive food, but stated that residents who communicate with the facility that they would like to be woken up for meals will be woken up. Per COO, a resident recently advised the facility they would like to be woken up for meals and now care staff are waking them up. The information obtained did not corroborate the allegation. Regarding the allegation that residents are not provided activities: it was alleged that the facility is not providing activities. Per the facility’s activity schedule, the facility has activities every day except Sunday. LPA Haddad inspected the facility and observed that activities are taking place at the facility with six to twelve residents participating in any given activity. Out of 10 residents interviewed, eight confirmed that the facility provides activities and some of these residents take great enjoyment from these activities, one resident was unaware whether there were activities, and one confirmed there were activities but stated there are fewer than there used to be. While the facility is providing activities, the information is conflicting regarding the quality and quantity of the activities. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegation are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Regarding the allegation that facility staff are not assisting residents when soiled in a timely manner: it was alleged that some residents are frequently left in soiled diapers or clothing for over 30 minutes. When interviewed, COO and two staff denied the allegation, stating that residents are changed when they are soiled and are checked on every two hours. Out of 10 residents interviewed, none reported any issues with personal care, staff responsiveness to their care needs, or the quality of care. No information was obtained corroborating the allegation. Regarding the allegation that facility staff do not provide enough food to residents: it was alleged that the meals are too small and that residents who request more are often told there is none available and provided a snack to tide them over. LPA Haddad reviewed the facility’s menu and noted a proper variety of foods offered. LPA Haddad inspected the facility and observed that residents received generous portions of food, residents left food on their plates that they did not finish, the facility had sufficient food supplies, and there were at least 15 extra plates of food that were not served and were extra available to residents who wanted more. LPA Haddad also noted that residents received food that they requested, for example one resident had five English muffins during breakfast. When interviewed, COO and one kitchen staff denied the allegation, stating that residents are given a sufficient portion, residents can request more food if they finished their first serving, and residents have access to snacks between and after meals. 13 out of 13 residents interviewed stated they get enough food at the facility. No information was obtained corroborating the allegation. Regarding the allegation that staff do not provide snacks to residents: it was alleged that staff are not serving snacks to residents anymore. Three staff interviewed denied the allegation, stating that snacks are available at all times and include apple sauce, yogurt, fruit, and peanut butter and jelly sandwiches. LPA Haddad inspected the kitchen and observed sufficient quantities of all of these items. Out of 10 residents interviewed, eight confirmed that snacks are available and two indicated they did not know whether snacks were available. No information was obtained corroborating that the facility is not offering snacks to residents. The Department has investigated the above allegations and found them to be Unfounded, meaning the allegations were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.