complaint·July 31, 2025

(Continued from LIC 9099) The Department interviewed thirteen of thirteen staff members, which include the former Chef and the current Chef at the facility. LPA also interviewed four of four alert residents. Seven of thirteen staff confirmed that on October 9, 2024 the dining room staff walked off the premises during dinner service. Six of the thirteen staff members interviewed were not employees of the community during October 2024. None of the staff members denied that the incident occurred. Three of the four residents interviewed recalled the incident when dining room staff walked out and that management voluntarily returned to the community to serve dinner and a family member also brought meals to the community. One of four residents did not reside in the community during this time. The allegation that: Kitchen staff is insufficient to provide meal services is Substantiated. Th is allegation was addressed on May 13, 2025 with the allegation that: Facility is understaffed to provide services necessary to meet resident needs with Complaint Control Number:22-AS-20250509094345. The Department conducted a ten day visit on October 15, 2024. LPAs interviewed the former Chef and spoke with three of three staff members. The Chef's interview stated the residents have access to food and that desserts, fruits and snacks are found in the bistro. LPAs took a photo of the bistro case and there observed three apples and six mini cakes in the glass casing. Three of the four residents LPA interviewed had various food issues and felt the food was not always accessible. In October 2024 there was a week between the former Chef leaving the community and the current Chef being cleared to work where food was not of adequate quantity or quality. This was primarily due to staffing shortages. Thus, the allegation that: Food service is insufficient in both quantity and quality is Substantiated. Based on LPAs observations, document review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations: Facility staff is insufficient to provide care and supervision to memory care residents, Kitchen staff is insufficient to provide meal services and Food service is insufficient in both quantity and quality are Substantiated. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Cynthia Figueroa, Executive Director and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 9099-D and Appeal Rights.