Complaint·March 6, 2026

Regarding the allegation of Facility is not reporting falls and other incidents involving residents revealed the following: 3 of 4 staff informed LPA that they report incidents to the Administrator. 1 of 4 staff informed LPA that they will write the reports and give them to the Administrator to submit them to licensing. 1 of 4 staff informed LPA that they had the incident reports but did not submit them to licensing. Upon records reviewed it was revealed that incident reports were written for Resident #1 (R1) that were not submitted to the Regional Office of Orange County. Regarding the facility allegation of Resident fell and sustained injuries due to a lack of supervision revealed the following: Records reviewed revealed a physicians report for R1 dated October 15, 2025, stating that R1 needs assistance with repositioning and transferring, is not able to dress, bathe or care for their own toileting needs. R1 was marked as non ambulatory due to their physical condition and unable to independently transfer to and from bed. This report was signed by a medical professional. LPA observed a needs and services plan dated January 22, 2026, stating that R1 has upper and lower extremity weakness and requires assistance with transfers and mobility. R1 was noted with poor safety awareness with attempts to get out of bed unassisted and has a history of falls. The needs and services plan states that R1 requires assistance with transfers and mobility and is often non-compliant. The plan also states that staff will assist R1 with their daily activities. LPA observed a staff schedule for the week of December 8, 2025, through December 14, 2025, that indicated 2-3 caregivers are on duty for the morning shift, 2 caregivers and a medtech for the evening shift and one caregiver and one medtech for the night shift. This schedule did not indicate any call offs for LPA to review. Interviews with staff revealed 4 of 4 staff informed LPA that there are normally 2 caregivers and a medtech on duty. 1 of 4 staff informed LPA that there is not enough staff to assist with resident needs. 1 of 4 staff informed LPA that they meet residents needs due to not having a choice regardless of staffing. 2 of 4 staff informed LPA that staff meet all residents needs. 1 of 4 staff informed LPA that the facility has staffing issues due to call offs. 1 of 4 staff informed LPA that they will take on caregiver duties to ensure resident needs are being met. 4 of 4 staff informed LPA that the facility does not have a housekeeper or a cook and caregivers do house keeping duties on top of their care giving duties. Interviews with residents revealed 2 of 4 residents informed LPA that there is a lack of staffing at the facility and it looks like the caregivers could use assistance. 1 of 4 residents informed LPA that they are independent and do not need much assistance. 2 of 4 residents informed LPA that their needs are met by staff. Continue on 9099C Based on interviews conducted, records reviewed and information gathered during the investigation, 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 and a copy of this report, LIC9099-D and appeal rights were left at the facility. LPA attempted to interview 1 of 1 bedridden residents and 1 of 1 were unable to confirm or deny the allegations. LPA observed staff assist with feeding 1 of 1 bedridden resident as soon as their food was ready. Regarding the facility allegation of Resident was able to elope due to a lack of supervision revealed the following: it was alleged that residents were able to elope from the facility due to a lack of supervision. LPA did not observe any incident reports regarding elopements from the facility. 2 of 4 staff informed LPA that there has not been an elopement at the facility to report. 1 of 4 staff informed LPA that when residents attempt to elope they are stopped at the front door due to the auditory device that signals the door has been opened. 1 of 4 staff informed LPA that a resident was recently redirected back to the facility after an attempted elopement. 1 of 4 staff informed LPA that if a resident has eloped and staff had to look for them, an incident report would be written. Based upon information gathered and interviews conducted, the Department is unable to ascertain if the above mentioned allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred: therefore the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility. LPA interviewed staff and 4 of 4 staff informed LPA that residents are given enough food and will be given more food when requested. 4 of 4 staff informed LPA that residents will be given alternative foods upon request. LPA interviewed residents and 3 of 4 residents informed LPA that they get enough food and can ask for seconds. 1 of 4 residents informed LPA that they never ask for seconds because they are given enough food to begin with. 1 of 4 residents informed LPA that they never get enough food. LPA observed 1 in 4 residents request food from staff and was provided with a snack. Regarding the facility allegation of staff are not adequately trained revealed the following: Upon records reviewed, LPA observed training records for 5 staff. LPA reviewed 3 of 5 staff have a skills checklist that went over training expectations and competency with the staff and a trainer both initialing all topics completed when first hired. 5 of 5 staff were hired in 2025. LPA reviewed current staff training on topics such as dementia, medications and care giving. LPA reviewed in service logs from September 2025 to November 2025 covering various topics such as bedridden residents, medication administration, documentation and infection control. LPA interviewed staff and 4 of 5 staff informed LPA that staff are trained when they were first hired. 2 of 5 staff informed LPA that staff are given shadow training and videos. Regarding the facility allegation of Residents are not allowed to open their windows or eat in their rooms revealed the following: LPA observed 1 of 4 resident rooms to have an open window. 2 of 4 residents informed LPA that they have no problems with opening their window. 3 of 4 staff informed LPA that residents are encouraged to keep their windows closed if the AC is on or if it is cold outside but they are not forced to keep them shut. 1 of 4 staff informed LPA that staff are not allowed to open the resident windows. Regarding the facility allegation Resident was injured by another resident due to a lack of supervision revealed the following: When reviewing the allegation there was not a concern due to the lack of supervision with resident on resident injuries. Based on information gathered the investigation into the above mentioned complaint allegations are found to be UNFOUNDED, meaning the allegation was false, could not have happened or is without reasonable basis. Therefore, the Department dismisses the complaint allegations. An exit interview was conducted and a copy of this report was left at the facility.