Complaint·December 12, 2025

CONTINUED FROM FORM LIC9099-A During the present visit, LPA requested the facility's resident census and toured the physical plant again. Additional resident records were requested and reviewed. Regarding the allegation that Staff does not ensure resident's diapering needs are being met , the following has been concluded: Based on assistance logs and incontinence logs provided, regular checks and diaper changes were being performed and documented during each shift in order to manage R1's assessed incontinence. Resident interviews failed to evidence any failure to address incontinence issues in a timely manner. Regarding the allegation that Staff does not ensure resident is provided clean clothing , the following has been concluded: During the initial investigation visit, LPA observed R1 relaxing in bed dressed in clothing that appeared to be free of visible stains and odors. Logs provided by facility staff appear to evidence due diligence conducted in order to ensure R1 was not provided with soiled clothing. Regarding the allegation that Staff does not ensure the safety of residents by monitoring entry and egress , the following has been conducted: Per the current plan of operation in place, the facility did not staff a front desk full time. However, facility policies required that visitors systematically sign-in as well as residents sign out prior to exiting the premises. Alert system preventing exits that would not be monitored are stated to be in place. Entry logs and sign-out logs were provided and appear to demonstrate most visitors do indeed abide by the facility's policy. As a result, all three allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099-A During the present visit, LPA requested the facility's resident census and toured the physical plant again. Additional resident records were requested and reviewed. Regarding the allegation that Staff does not ensure residents are provide adequate bedroom lighting , the following has been concluded: During the initial complaint investigation visit, LPA observed ceiling lights in addition to an accessible lamp by the side of R1's bed. Lamp was verified to be in operation. Per resident interview, staff was available to turn the light on if R1 wished to benefit from brighter lighting. As a result, the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 During the present visit, LPA toured the physical plant again. Additional resident records were requested and reviewed. Regarding the allegation that Staff does not ensure resident is provided a comfortable living space , the following has been concluded: Based on observation conducted during the initial investigation visit, it was determined that during a COVID outbreak that occurred at the facility in September 2025, R1 was moved from unit #153 to unit #167 where she was during the initial visit. Unit 167 was assigned to resident R1 along with another resident was divided unevenly between the two residents as multiple storage boxes were placed at the foot of R1's roommate's bed. The partition used did not leave sufficient circulation room on both sides of the bed in order for R1 to transfer safely onto their wheelchair. R1 eventually returned to unit 153B which was set up differently and provided sufficient space until they moved out on November 21, 2025. Regarding the allegation that Staff does not ensure resident's health needs are being met , the following has been concluded: During the investigation, photographs were provided showing that R1's lower extremities were not being attended to and their toe nails were not being trimmed. Staff interviewed stated that it had been assumed that the resident's home health provider was in charge of these health needs, however a review of R1's home health plan of care in place at the time found no indication that this was actually the case. As a result, both allegations are found to be Substantiated, meaning that the preponderance of evidence threshold has been met. See attached form LIC9099-D 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.