Complaint·October 29, 2025

Upon interviews with Staff 1(S1) it was revealed that they sent staff to the grocery store because they knew the food was going to be an issue. Therefore, the allegation has been deemed Substantiated. Regarding the allegation of staff installed video camera with audio without resident’s consent revealed the following: LPA toured the facility and observed a camera in room four. LPA observed text message screenshots with Resident 1s (R1) responsible party with S1 stating that on August 28, 2025, the camera was installed with a live feed picture of room four showing the two residents’ beds. LPA observed text messages from S1 saying that R1 had been informed of the camera and that they will be in R1s room indefinitely. At the time of the inspection S1 showed LPA that the feed is offline and no longer connected to the camera. S1 informed LPA that they left it there even though the feed is offline due to resident complaints going down since it has been installed. S1 informed LPA that they asked the responsible parties of the residents in room four to gain consent before installing the camera. S1 informed LPA that they are the only one that has access to the camera feed. Staff 2 (S2) informed LPA that it was suggested by S1 to put the camera in room 4 and that they asked the responsible parties of room 4 for consent. S2 informed LPA that the residents are not conserved and that S1 was the only one with access to the camera feed. Interviews with R1 revealed that they were not asked if they wanted the camera, but their responsible party gave consent. LPA did not observe conservatorship papers for R1 for this decision to be made on R1s behalf. LPA observed staff remove the camera from room four entirely at the time of the investigation. Therefore, the allegation has been deemed Substantiated. Regarding the allegation, staff did not ensure residents have hot water in the bathroom revealed the following: LPA toured the facility and went into R1s room and tested the water to be at 109.4 degrees Fahrenheit in room 3 at the time of the investigation. S1 informed LPA that a plumber came to the facility to fix R1s shower faucet due to it being stripped and unable to turn to the hot water side. R1 informed LPA that they had to go to another room multiple times to shower until their shower was eventually fixed. LPA observed a work order from a handyman stating that on October 3, 2025, they removed and installed a new faucet at the facility. Therefore, the allegation has been deemed Substantiated. Based on information gathered, interviews and records reviewed the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC9099D. An exit interview was conducted with AD Melinda Flores and a copy of this report, LIC9099D and appeal rights were left at the facility. S1 informed LPA that most of the food offerings are on the diabetic diet already. S1 informed LPA that they only buy sugar free or Splenda alternative desserts and offer that to all residents in care. LPA observed a physician’s order dated June 16, 2025, stating that R1 cannot have barbecue flavored foods. During interviews it was revealed that four of four staff follow dietary restrictions and physician’s orders. Four of four staff informed LPA that they are aware of all residents who have dietary restrictions in the facility. LPA interviewed seven residents and two of seven have a special diet. One of seven residents informed LPA that staff follow their dietary restrictions. Two of seven residents informed LPA that they do not have dietary restrictions and four of seven residents could not tell LPA if they had any dietary restrictions. LPA observed 3 of 3 residents having their dietary restrictions being met during breakfast meal service. Therefore, the allegation has been deemed Unsubstantiated. Regarding the allegation staff interacts with resident in an inappropriate manner revealed the following: upon interviews with residents two of seven residents informed LPA that they have been embarrassed or insulted by staff at the facility. One of seven residents informed LPA that they have been yelled at by S1 and S1 denied the allegation. Four of four staff informed LPA that they have never observed staff yell, embarrass or insult residents in care. LPA observed that on June 11, 2025, S1 conducted an in-service training for staff regarding resident rights. Therefore, the allegation has been deemed Unsubstantiated. Regarding the allegation staff did not dispose of needle after use revealed the following: It is alleged that staff left R1s needle that goes into their glucose monitoring machine on their bed. Upon interviews it was revealed that four of four staff informed LPA that R1 uses a machine to test their glucose levels. Staff store it and put it together for R1 before R1 uses the machine themselves. One of four staff informed LPA that staff deposit the used needle in a bin on the medication cart for R1. Three of four staff are unaware of an incident that may have taken place and one of four staff was told about the incident and the care staff in question denied the allegation at the time of the incident. R1 informed LPA that they were sitting up in bed when they noticed something on their pillow and informed LPA that it was a needle that had been left by staff. Therefore, the allegation has been deemed Unsubstantiated. Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations that staff do not ensure resident's dietary needs are met, staff interacts with resident in an inappropriate manner and staff did not dispose of needle after use are deemed UNSUBSTANTIATED. Therefore, the Department dismisses the allegations. An exit interview was conducted and a copy of this report was left at the facility. R1 informed LPA that they thought the signal system was not working due to not being able to hear the beeping anymore and had not pulled it for a few days. R1 informed LPA that the staff normally come when they use the pull chord. LPA observed R1 use the pull chord and receive assistance during the course of the interview. Three of seven residents informed LPA that they have never had to use the pull chord and three of seven residents informed LPA that they could not recall if they have had to use the signal system for help. LPA tested the signal system and observed it to be working and signaling staff with beeping. LPA observed the response time of care staff to be within a minute of pulling the chord. Therefore, the allegation is Unfounded. Regarding the allegation staff do not ensure a complete first aid kit is maintained at the facility revealed the following: It was alleged that the facility did not have a thermometer for resident use upon request. Upon interviews with Witness 1(W1) it was revealed that the facility did have a thermometer but the care staff they requested it from did not look in the proper spot. LPA observed a complete first aid kit at the facility which includes: sterile first aid dressings, bandages, scissors, tweezers and a thermometer. Therefore, the allegation is Unfounded. Based upon LPAs observations, interviews and information gathered during the investigation, the preponderance of evidence standard has not been met, therefore the above allegations are deemed UNFOUNDED. Meaning the allegations Staff do not respond to resident's calls for assistance and Staff do not ensure a complete first aid kit is maintained at the facility, could not have happened and/or is without a reasonable basis. The department therefore dismissed the complaint. An exit interview was conducted and a copy of this report was left at the facility.