complaint·August 6, 2025

It was alleged that Resident #1 (R1) was not showered for multiple days. Seven staff interviewed denied the allegation, stating that R1 received showers at least twice a week, R1 rarely refused showers, and that if R1 did refuse a shower facility staff would attempt multiple times to complete the shower for R1. Seven out of seven residents interviewed did not raise concerns about not receiving enough showers. However, review of the facility’s shower log revealed that R1 did not receive a shower on October 5, 6, 7, 8, 9, 10, or 11, 2024, and while a single refusal was documented on October 8, 2024, there is no documentation of additional attempts to offer R1 a shower until another single refusal was documented on October 11, 2024. AD reviewed the shower log and confirmed that it shows that R1 did not receive a shower during this period. While R1 had the right to refuse showers, facility staff did not make and document multiple attempts to assist R1 with showers. The information obtained corroborated the allegation. 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 safeguard resident's personal items: it was alleged that R1’s shaver disappeared and that they were observed wearing their roommate’s underwear. Seven out of seven staff interviewed denied the allegation, stating that personal items and clothing are logged, the facility will look for and replace any missing items, residents sometimes do inadvertently take clothing that is not theirs, but that staff will wash and return any clothes taken by other residents if they are made aware of the issue. Review of R1’s inventory lists revealed that R1's clothing and personal items were thoroughly itemized, but the lists did not include a shaver. Seven out of seven residents interviewed raised no concerns about missing items or mixed-up clothing. While incidents of items going missing and residents’ clothing getting mixed up may happen occasionally, the information obtained did not corroborate that the facility is not taking sufficient measures to prevent these issues. Regarding the allegation that staff allow residents to use the same toothbrush: it was alleged that, in R1’s bathroom which R1 shared with their roommate, three toothbrushes were observed in the same cup and only one shaver, indicating that both residents are using the same shaver and potentially the same toothbrush. Seven out of seven staff interviewed denied the allegation, indicating that residents have their own labeled storage area in the bathroom for their hygiene items. Two of these staff stated that residents are assisted by staff while brushing their teeth. LPA Tirre observed that residents had personal labeled storage spaces for their hygiene items in their bathrooms. LPA Haddad inspected the toothbrushes for seven residents and noted that toothbrushes were either locked in the bathroom storage closet, accessible on the bathroom counter and labeled with resident names, or accessible on the counter if the resident had no roommate. Interviews with seven residents revealed that residents are either aware of which toothbrush is theirs and are able to access them or they receive assistance from staff when it is time to brush their teeth. While it is possible that residents are using the toothbrushes of other residents while staff are not present to assist them, the information obtained is conflicting. Regarding the allegation that staff did not prevent resident from engaging in an altercation with another resident in care: it was alleged that R1 engaged in two altercations with another resident and that facility staff did not prevent this from occurring. Per R1’s Physician’s Report dated July 16, 2024, R1 is diagnosed with Dementia, is ambulatory, and has confusion, aggressive behavior, and wandering behavior. Seven out of seven staff interviewed denied the allegation, stating that residents who engage in altercations are separated and that measures are taken to prevent future altercations. Two staff interviewed confirmed that R1 got into two altercations with another resident and that in response to the first altercation the facility placed R1 on one-on-one supervision for 72 hours and requested a medical reassessment including significant medication adjustment for R1. Per R1’s care notes, on October 16, 2024, at 6:30AM, R1 was involved in an altercation where R1 pushed another resident to the ground and facility staff notified R1’s family that due to R1’s behavior, R1 needs one-on-one supervision and a medication change. No information was obtained that R1 did not receive the one-on-one care as required. Per R1’s Medication Administration Record, R1 received all of their medications as prescribed in September and October 2024. Per AD, facility staff and R1’s family agreed that R1’s current doctor was not responding to the situation properly, so it was agreed to have R1 seen by a new doctor, R1’s family fully participated in the care plan meeting with the new doctor, agreed to the medication changes, and agreed for the medications to be sent to a new pharmacy since the new doctor was not allowed to send the medication order to R1’s old pharmacy. The information obtained regarding the second altercation is conflicting. Per witness statement, the second altercation took place on October 20, 2024, but per R1’s care notes and AD, the second altercation was a verbal altercation that took place on October 24, 2024. No information was obtained that there were any physical altercations involving R1 after the October 16, 2024, altercation. It was also alleged that R1 was bullied by the resident they pushed, that this other resident was witnessed bullying other residents and R1 multiple times, and that R1’s family requested the facility to keep them separated but facility staff did not properly redirect them when they got into verbal altercations or the other resident bullied R1. However, the only confirmed physical altercation took place on October 16, 2024, where R1 was the physical aggressor and the information obtained showed the facility properly addressed R1’s aggression. Seven out of seven residents interviewed reported they received good care at the facility and reported no concerns about their safety. While there may have been instances of bullying between residents, the information obtained did not corroborate that the facility did not properly address resident conflicts when they rose to the level of physical altercations. 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.