Complaint·April 28, 2026

(Continued from LIC 9099) Per Physician's Report dated 8/20/2025, Resident #1 (R1) has primary diagnoses of osteoporosis and osteoarthritis. R1 does not have mental cognitive impairment but has a history of behavior expression of paranoia. R1 is independent and does not require assistance with mobility/ambulation. Per medical assessment the resident is non-ambulatory due to physical condition diagnoses. R1 is capable of administering their own medications. The pre-appraisal from 8/11/2025 states R1 doesn't prefer to be social but is encouraged to join activities. R1 is capable of doing their own laundry and household tasks. Per R1's Care Plan R1 has a history of occasional anxiety and depression or mood disorder. It was alleged that: Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others. Per LPA staff and resident interviews, R1 usually comes to the dining room for dinner. A comment was made, at the dinner table that female residents stink. Another resident at the table then covered their nose. R1 felt the comment was made towards them. LPA interviewed six of six residents. Three residents at the table were interviewed. One resident confirmed the allegation, a second resident denied the allegation and the third resident moved out of the community and could not be interviewed. Two additional residents were interviewed and denied the allegation. The allegation that Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others is Unsubstantiated. LPA investigated the allegation that Staff do not ensure resident is provided personal privacy. Staff were instructed to conduct a room check for a resident's missing laundry. Two staff members knocked on R1's door and requested entry. The staff stated they were looking for a resident's missing laundry items and requested permission to look in R1's closet and dresser. R1 permitted entry to search for the missing items. R1 does not use laundry services and is able to do their own laundry. Several days later, R1 shared the incident with management, stating they were not afforded privacy and that the staff members entered while R1 was in the bathroom. Staff and management are aware that R1 prefers to be private and so staff will enter the apartment in pairs as needed, to ensure R1 is more at ease with staff. R1 is independent and does not require a lot of services and staff do not enter R1's apartment often. One resident confirmed the allegation and three residents denied the allegation. The allegation that Staff do not ensure resident is provided personal privacy is Unsubstantiated. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) It was also alleged that Staff do not ensure resident is spoken to in an appropriate manner. It was reported to management that two persons entered R1's apartment and were asking questions about R1's medications and medical information. The incident occurred on a Saturday and management was not aware of the incident until Monday. Management interviewed staff and reviewed facility hallway cameras. It was determined the two people visiting were a Physician's Assistant (PA) and Social Worker (SW) from the Primary Care Provider agency; whom R1 permitted entry. R1 also reported that another staff member made inappropriate comments while watching an evening movie. When asked what the comments were, R1 referred to a film the staff member was discussing. The staff member has since resigned and left the community. One resident confirmed the above allegation and three residents denied the allegation; stating staff are always professional and courteous. Five of five staff interviewed all denied the allegation. Thus the allegation that staff do not ensure resident is spoken to in an appropriate manner is Unsubstantiated. LPA investigated the allegation that: Staff do not ensure resident is served meals in a timely manner as a form of punishment. It was reported to LPA that dining staff did not provide a meal at dinner to punish the resident. LPA interviewed five of five staff members who denied the allegation. Three of five residents interviewed also denied the allegation. One resident was unavailable to interview who were present. Staff interviews shared that R1 had eaten an entree and, later, ordered another entree. The server took the second entree order but, as the staff member was walking to the kitchen, was delayed by another table. The order was then placed with the chef. As the residents at R1's table received their initial dinner orders, one of the residents inquired about the second order for R1. The server stated the order was placed but R1 immediately got up from the table and left the dining room. This was brought to management's attention and the chef spoke with R1 about the incident and assured R1 it was not a delay to punish the resident and the order was completed. Thus the allegation that Staff do not ensure resident is served meals in a timely manner as a form of punishment is Unsubstantiated. (Continued on LIC 9099-C2) (Continued from LIC 9099 C1) Based on LPA's file review, observations and interviews the allegations that: Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others, Staff do not ensure resident is provided personal privacy, Staff do not ensure resident is spoken to in an appropriate manner and, Staff do not ensure resident is served meals in a timely manner as a form of punishment are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Executive Director (ED) Cynthia Figueroa and a copy of this report,and LIC 811 were provided to the facility. ***This is an amended report.***