complaint·June 18, 2025

(Continued from LIC 9099) It was alleged staff are not meeting residents showering needs due to resident 2 (R2) not receiving showers. LPA conducted interviews with ten of ten staff who reported R2 is independent in showering needs and does not require shower assistance. LPA interviewed four of four residents who did not report any concerns of body odors or smells from R2. LPA Hanna Gough interviewed R2 and stated to LPA that he does showers himself and nobody helps him. Per R2’s physician report dated June 10, 2023. R2’s needs and assessment dated March 20, 2025, R2 is independent in showering and does not require assistance. LPAs Ruppert and Gough spoke with ED Cynthia Figueroa and HWD regarding R2’s showering needs and will set-up a care plan meeting with family. It was alleged staff are falsifying residents LIC 602's due to Executive Director changing residents LIC602’s when a resident complains or questions director in an effort to move residents to facility memory care. It was reported LIC602’s were changed for Residents #3, #4 and #5 (R3; R4; R5). Per R3’s physician report dated February 24, 2025, R3 has a diagnosis of hepatic encephalopathy. The report was signed by MD Woo who was treating R3 for less than one month. Due to R3’s confusion, wandering and sundowning behavior at time of admission, R3 was re-evaluated on March 01, 2025, and was diagnosed with mild cognitive impairment and placed on hospice services. R3 moved into Assisted Living on February 28, 2025. On March 2 2025 R3 was transferred to Memory Care which was the appropriate placement. Per physician report dated March 05, 2025, R4 has a diagnosis of dementia. Physician report was completed by R4’s primary care physician who treated R4 for the past five years prior to moving into the facility. A new Physician’s Report for R4, dated May 12, 2025, was conducted and an assessment is being obtained Family communicated with ED Figueroa to have R4 to transfer to Assisted Living but R4 currently resides in Memory Care. Resident #5 recently passed away and was never a candidate to move into Memory Care. LPA interviewed R5’s Power of Attorney (POA) who stated R5 was residing in facility assisted living unit and had no intentions to move resident to memory care unit. Per POA, there were no concerns of R5’s LIC602 being re-evaluated and/or changed improperly. LPA interviewed ten of ten staff who denied the allegation. (Continued on LIC 9099-C1) (Continued from LIC 90990-C) It was alleged Staff are not providing a comfortable environment due to being told not to speak to Community Care Licensing and hide information. LPA interviewed seven of seven staff who denied the allegation. LPA interviewed five of five residents who denied ever being told to not speak to licensing or hide information. LPA reviewed ten of ten staff member training records and observed mandatory reporter training is current and up to date. LPA observed required PUB475 posted in a prominent place notifying residents of the right to report concerns to Community Care Licensing. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations that: Staff are not following infectious protocols for residents, Staff are not meeting residents showering needs, Staff are falsifying residents LIC 602's and Staff are not providing a comfortable environment are Unsubstantiated. An exit interview was conducted with ED Figueroa and a copy of this report and LIC 811 Confidential Names were provided to the facility.