complaint·February 19, 2026

LPA observed residents were served based on the dining menu which was chorizo scrambled eggs with toast or hot or cold cereal. Based on the interviews, four out of eight residents and four out of eight staff confirmed the delay in meal service. Three out of the four residents who confirmed the allegation were interviewed in October 2022. The three residents indicated that the wait time in the dining room in 2022 was approximately 1-2 hours due to staff shortages which was also confirmed by Executive Director Melanie Washington. Regarding the allegation, Residents are being left in soiled diapers for an extended amount of time, it is alleged that the residents are left in soiled diapers for hours. Based on the interviews, six of eight residents and three of eight staff confirmed the delay. Six residents reported waiting to get changed 30-45 minutes after the pendant was pressed with one of the six residents reported waiting 3 hours. The investigation revealed that the staff turnover caused delays in serving food on or approximately October 2022 and the wait time for diaper changes would range between 30-45 minutes. Therefore, based on LPA's observations, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations, Residents are not being provided adequate food service and Residents are being left soiled in diapers for an extended amount of time are deemed SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D. An exit interview was conducted with Assistant Executive Director Monica Aguirre, and a copy of this report including the appeal rights were provided at exit.