complaint·April 7, 2026

During their interview, Witness 1 (W1) corroborated the allegation and stated they had been present at the time R1 was served with pork and provided LPA with a picture of R1’s plate from that date, consisting of pull pork, mixed vegetables, and mashed potatoes. Regarding the allegation, Insufficient staff to meet resident's needs, the following was revealed: It is alleged that on March 23, 2026, R1 was being changed by Staff 1 (S1), and S1 alone, however, R1 requires a two person assist for diaper changes. During their interview, R1 was unable to confirm or deny allegation. During their interview, S1 corroborated the allegation and stated they were aware R1 required a two person assist, however, assisted R1 with incontinence care alone, as no other care staff was available. Per W1, they had been present at the time and they had to assist S1, as no other care staff was available to assist. Regarding the allegation, Responsible party was not notified of resident's change in condition, the following was revealed: It is alleged R1’s responsible party was not notified of R1’s bed sores. During their interview, R1 was unable to confirm or deny allegation. During their interview, W1 stated that on March 23, 2026, they discovered bed sores on R1, and facility staff had not notified them. During their interview, Staff 2 (S2) corroborated the allegation and stated it had been W1, who informed them of R1’s bed sore. Per Staff 3 (S3) they had notified R1’s responsible party and provided LPA with an email and phone call notification, however, email and phone call were not placed until April 3, 2026. Based on staff and witness interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Deficiency are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided at the end today's inspection. During the course of the investigation, LPA obtained a copy of Internal Occurrence Report and interviewed R1’s family members, Witness (W1) and Witness 2 (W2). Per Internal Occurrence Report (IOR), R1 was found on the floor in their bedroom on March 26, 2026 at 5:30 a.m. IOR does not indicate whether or not the bed rails were in place at the time of the fall. Per Staff 2 (S2), however, the bedrails were in place. During their interview, R1’s family member, W1 stated they did not have a doctor’s order for compression socks and stated one may have been provided to R1 some time ago but was unsure if R1 had a current doctor’s order. Per W1, R1 did have a fall from bed recently and facility staff were unable to confirm if the bedrails had been in place during the night. During their interview, W2 also stated they were unsure if a doctor’s order for compression socks had been obtained and stated W1 had a background in healthcare and may have believed it was best that R1 wear compression socks. W2 denied having any knowledge of whether or not R1’s bedrails were being used. Regarding the allegation, Resident was not accorded sufficient space in their accommodation, the following was revealed: It is alleged R1’s bed is pushed to the side and the room is not shared equally as R1’s roommate has more space for their belongings. During their interview, R1 was unable to confirm or deny whether or not they are accorded sufficient space in their accommodation. During their interview, R1’s roommate, R2 denied the allegation and stated the bedroom space is divided evenly and both they and R1 are able to move about the room comfortably with their wheelchairs. Two of four additional residents interviewed, denied the allegation and stated they are accorded sufficient space in their bedroom accommodation. Two of four residents were unable to confirm or deny the allegation. During their interview, three of three staff denied pushing or moving R1’s furniture aside, and stated that resident bedrooms are divided evenly, and there is no preference for one resident’s space or accommodation over the other. Regarding the allegation, Staff left resident in unhygienic conditions, the following was revealed: It is alleged that during a diaper change, Staff 1 (S1) did not remove their gloves when placing the new diaper and smeared feces onto R1’s clothing. During their interview, R1 was unable to confirm or deny whether or not they had been left in unhygienic conditions. During their interview, S1 stated they only assisted R1 with a diaper change on one occasion, however, denied wearing soiled gloves or smearing feces on R1. Per S1, their gloves were clean, and it is facility protocol to remove their gloves after assisting a resident with incontinence care. Interviews were conducted with five additional facility residents and two staff. One of five residents was unable to confirm or deny allegation and four of five residents denied being left in unhygienic conditions by staff. (Cont. LIC9099-C) Two of two staff denied having any knowledge of R1 or any other resident being provided with incontinence care by a staff member with soil gloves and stated it is facility protocol to wear clean gloves and to remove their gloves after assisting a resident with incontinence care. Due to conflicting information received during interviews conducted, LPA is unable to determine if Resident's needs were not met, if Resident was not accorded sufficient space in their accommodation, or if Staff left resident in unhygienic conditions. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.