Inspector’s narrative
What the inspector wrote
It was alleged that R1, who was back on their rent because they could not afford the full amount, was advised that they needed to leave the facility immediately on June 20, 2022, as part of a 3-Day Eviction, and told they owed an incorrect amount. On June 17, 2022, LPA received a 3-Day Eviction Notice dated June 16, 2022, from COO for R1 on the basis of non-payment of rent, which COO withdrew that same day and later issued a 30-Day Eviction Notice dated June 17, 2022. While COO claimed the 3-Day Eviction Notice dated June 16, 2022 was not served on R1, R1 confirmed they were told by COO that their eviction was a 3-Day Eviction and they would have to leave on June 20, 2022, which corroborates that R1 was unlawfully evicted verbally as R1 otherwise would not have known about the 3-Day Eviction or the end date of the notice period. Regarding the back owed rent, R1’s Admission Agreement indicates R1’s monthly rent was $2,700. Per R1’s Written Statement to the Facility dated June 21, 2022, R1 and COO agreed that “[R1] could ‘not’ pay more than $1,400 per month.” However, COO denied that R1’s rent was reduced from $2,700 to $1,400 per month and there is no written documentation of this modification to R1’s Admission Agreement. R1’s Billing Statement indicates that R1 was indeed given a discount from $2,700 to $2,000 per month, but that this amount was not fully paid and as of June 16, 2022, R1’s outstanding balance was $8,735. LPA interviewed COO who stated that the $2,700 monthly rent was already discounted from $4,000, COO worked with R1’s family to obtain financial support for R1, R1 could only pay $1,400 per month but also made no payments for multiple months, and the facility never agreed to accept $1,400 as total payment for R1’s rent. Per COO, there were no irregularities with R1’s billing and the total amount owed is correct.
During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. 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 staff did not prevent residents from engaging in inappropriate behaviors: it was alleged that Resident #2 (R2) was observed using the common bathroom on the first with the door open, Resident #3 (R3) was observed urinating in a public area, and R3 was observed walking around the facility with their pants down. LPA interviewed COO who confirmed that the incident with R3 urinating in a public area was reported to them, but stated that the issue was addressed with R3 and R3 has not engaged in any similar behavior for a long time since. COO was unable to provide information about the other two alleged incidents, but stated that staff address all inappropriate behavior with residents when they observe it or learn of it from other residents and if residents continue to engage in inappropriate behavior after being warned the facility will begin the eviction process. LPA interviewed 12 residents who did not corroborate that staff are not addressing inappropriate behavior.
Regarding the allegation that staff did not prevent resident from making inappropriate comments towards another resident: it was alleged that R1 observed R2 using the shared bathroom with the door open, R1 advised R2 to close the door, and R2 responded with an expletive. Per R1’s Written Statement to the Facility dated June 3, 2022, in response to R2’s expletive, R1 responded with the same expletive. LPA interviewed COO who was unable to provide information about this particular incident, but stated that staff address all inappropriate comments with residents when they observe it or learn of it from other residents and if residents continue to make inappropriate comments after being warned the facility will begin the eviction process. LPA interviewed 12 residents who did not corroborate that staff are not addressing inappropriate comments.
Regarding that allegation that a resident is not awarded privacy: it was alleged that, despite R1 advising staff to knock before entering their room, staff enter their room without knocking and in one instance a medication technician entered R1’s room without knocking in order to ask R1 if they needed assistance. Per COO, staff are trained to knock before entering a resident’s room, R1 never reported any concerns on this topic to the facility, and it is possible that hearing issues may have prevented R1 from hearing the staff knock. LPA interviewed 12 residents who did not corroborate any concerns with privacy or the way staff enter residents’ rooms.
Regarding the allegation that residents toilet is in disrepair: it was alleged that R1’s toilet does not always work and that they sometimes have to use the common bathroom on the first floor. When interviewed, R1 stated their toilet had been fixed on or before June 21, 2022, did not report any concerns with the facility’s efforts to fix their toilet, and noted their main concern was something they observed in the common bathroom on the first floor. LPA interviewed COO who was unable to provide specific information regarding R1’s toilet but stated that broken items are addressed as quickly as possible by maintenance. LPA inspected the toilets in 11 rooms and observed them to be working properly. LPA interviewed 12 residents who did not corroborate any concerns about the fixtures in their room or the facility’s efforts to repair items when they break.
Regarding the allegation that staff are not providing adequate food service to resident: it was alleged that R1 cannot have sugar, beef, shellfish, or pork and the facility’s menu has limited options to accommodate their diet. When interviewed, R1 stated they did not have a doctor’s order for this diet. LPA reviewed R1’s Physician’s Report that indicates R1 is allergic to shellfish and should avoid red meat. LPA interviewed COO who stated that the facility has special diets for residents with low sugar or low salt needs, as well as multiple options for residents who have personal preferences. Per COO, most of the facility’s menu avoids shellfish and beef, so it is always possible to get food without these ingredients, and the facility’s menu has not substantially changed since 2022. LPA interviewed 12 residents who did not corroborate any concerns about the quality of food or their ability to choose what items they want. LPA reviewed the facility’s menu for March 2026 and noted there are options that do not include sugar, beef, shellfish, or pork on almost all days and per COO and residents interviewed, the facility will make residents’ requested items if they do not want what is on the menu.
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 allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
