complaint·April 28, 2026

Interviews with one out of five residents stated the facility has remained in good repair overall. The remaining four residents could not be qualified for interviews. Interviews with three out of three staff stated there are maintenance persons who are available to make repairs to the facility as needed. Regarding the allegation facility is not adequately staffed, it was reported there is insufficient staff to meet the needs of the residents. LPA interviews with one out of five residents stated their needs are being met by staff and there has not been an issue with staffing. The four remaining residents could not be qualified for interviews. Three out of three staff stated there is sufficient staff coverage and several back up staff is available when needed. LPA record review of the LIC500 indicates there are seven caregivers available or on call with at least two caregivers scheduled to work from 7AM to 8PM and one caregiver scheduled to work from 8PM to 8AM. LPA reviewed schedule indicating two staff during the day shift and one staff during the night shift from March to May 2026. Based on interviews and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report was left with the facility. Based on interviews and records observed, the allegation is therefore deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of the report was left with the facility representative. S1 added there has never been an instance where medications were not available or delayed. During the initial complaint visit conducted by the Department on December 14, 2023, it was observed Miralax was available at the facility. When the Department questioned who the Miralax belong to, staff stated it belonged to Resident 7 (R7). The Department did not observe Miralax in R7's medication administration record. The staff removed the Miralax from the facility and stated they would obtain a physician's order to provide to R7. Record review revealed R7 moved out of the facility on October 14, 2024. LPA reviewed R7's medication administration record for the months of September, October, and November 2023. LPA also reviewed medication list from hospice for R7 dated October 7, 2023. Neither indicates Miralax or Polyethylene Glycol Powder as part of R7's medications. Regarding the allegation facility failed to maintain a complete and accurate resident’s records, it was reported resident records and not maintained per Title 22 regulations. The centrally stored medication and destruction record for R7 was not available to review. Administrator (AD) Kian Pascual stated those records were lost when the facility transitioned into their current record keeping system. Based on interviews conducted, records reviewed, and observations, 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 LIC 9099D. An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.