complaint·August 18, 2025

Regarding the allegation that staff do not ensure recliners and chairs are in good condition: it was alleged that the chairs in the memory care are falling apart and the recliners are broken. LPA inspected the facility and observed multiple chairs, couches, and recliners not in good repair, including the cloth recliners in the second-floor memory care that were heavily stained and are unsanitary, and the leather recliners in the second-floor memory care where the leather was torn or flaking off. The information obtained corroborated the allegation. Regarding the allegation that staff did not ensure elevators are functional and accessible: it was alleged that one of the facility’s elevators has been broken for over a year and the elevator that is used for emergencies is covered with clutter which is dangerous in the case of an emergency. LPA reviewed the facility sketch which indicates the facility has three elevators: one on the north side near the dining room; one on the southeast side near the laundry room; and one on the southwest side. LPA inspected the facility and confirmed the elevator on the north side near the dining room is operational. Per facility staff, this elevator is the only one used by residents. LPA observed that the elevator on the southeast side near the laundry room is non-operational. Per facility staff, this elevator was used by memory care staff to enter and leave the memory care units, it has not been working for some time, efforts to repair it have been unsuccessful, and the facility has decided to decommission this elevator. LPA observed that the elevator on the southwest side is operational, but the entrance on the first floor is obstructed by furniture. Per facility staff, this elevator is used for emergencies, is not generally used, and the entrance should not be blocked by furniture. The information obtained corroborated that one of the facility’s three elevators is non-functional and that a second elevator is inaccessible due to being obstructed by furniture. Regarding the allegation that staff do not ensure urine and feces on floors and furniture is cleaned with appropriate chemicals: it was alleged that the third-floor memory care common area is covered in urine and feces and staff do not have proper cleaning supplies and have to clean with water and hand soap from time to time. LPA inspected the facility and observed the facility to be generally clean and free from foul odors. LPA observed multiple housekeepers cleaning the facility with appropriate chemicals. However, LPA inspected the third-floor memory care and noted there is no cleaning closet or access to appropriate chemicals. Per facility staff, if the caregivers on the third-floor memory care needed to clean a mess, they can call the front desk and have cleaning supplies delivered to them. However, facility staff also stated that there are no housekeepers at the facility between 4:00PM and 6:00AM and that sometimes the caregivers will leave a mess for the housekeepers to clean when they arrive because that is the job of the housekeepers. Based on the information obtained, the caregivers in the third-floor memory care do not have immediate access to appropriate cleaning chemicals to clean messes as they arise and also have a practice of leaving messes for the housekeepers to clean up possibly much later as the facility does not have housekeepers available for 14 hours each day. 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. LPA reviewed the facility’s pest control records which show that the exterminator comes to address pests at the facility regularly. LPA interviewed 10 residents and did not obtain information corroborating the allegation. The information obtained did not corroborate the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.