complaint·December 19, 2025

Regarding the allegation, “Staff did not meet reporting requirements” it was alleged the facility failed to meet the mandated reporting requirements after a resident suffered a broken leg from a fall in the facility. It was further alleged that a different resident had falls on 06/13, 06/14, 06/16, 06/18 and multiple visits to the emergency room that were also unreported. The residents were identified by their room numbers. The resident identified in the allegation who allegedly had a broken leg was identified as Resident 1 (R1). There were a total of five (5) staff interviewed. One (1) of five (5) staff interviewed was unable to recall any resident breaking their leg in the facility. The remaining four (4) of five (5) staff interviewed reported, R1 never broke their leg in the facility. LPA attempted to conduct an interview with R1 to inquire whether they suffered a broken leg while at the facility. However, R1 was unable to participate in the interview. LPA also made attempts to contact R1’s responsible party but was unsuccessful. LPA reviewed Unusual Incident/Injury Reports (LIC 624s) regarding Resident 2’s (R2) unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 which were reported to Community Care Licensing (CCL) timely. The reports documented 911 was called each time, and each time R2 was transported to the hospital for further evaluation. The reports also indicated R2’s responsible party and primary care physician were notified. LPA made contact with R2’s responsible party who reported R2 has since passed away. The responsible party reported that facility staff notified them of multiple falls R2 experienced in the facility and was aware R2 was sent to the hospital for evaluation. However, the responsible party was unable to recall exact incident dates and therefore was unable to confirm whether the facility reported every fall to them since R2 exhibited memory loss and RP was not always in the facility. Five (5) of five (5) staff interviewed reported the facility follows mandated reporting requirements and activates emergency services each time a resident has an unwitnessed fall or incident. Five (5) of five (5) staff interviewed added they have never suspected staff abuse or neglect led to the resident incidents and/or falls which include any incidents involving R1 and R2. It was reported that this is why the incidents were reported to CCL but not the Long-Term Care Ombudsman nor Law Enforcement. Mandated reporting requires reports to the local ombudsman, the corresponding licensing agency and local law enforcement when the mandated reporter reasonably suspects physical abuse, abandonment, abduction, isolation, financial abuse or neglect. However, five (5) of five (5) staff interviewed reported they did not reasonably suspect abuse or neglect regarding R2's unwitnessed incidents. BOM Anguiano also reported the facility is not aware of any other incidents involving R2 on the alleged dates. Regarding the allegation, “Staff did not comply with infection control requirements” it was alleged every resident was observed itching and scratching themselves and none of the staff was observed to have personal protective equipment donned such as gloves, masks, etc. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents reported they did not have knowledge or recall the facility having an outbreak where multiple residents were observed to be scratching themselves. The remaining two residents were unable to provide information. Three (3) of three (3) staff interviewed reported the following information. Facility housekeepers are constantly cleaning, disinfecting the facility, and/or following universal precautions. They are unable to recall an incident where every or multiple residents were observed to be itching or scratching themselves. In June 2024, the facility did not experience any sort of outbreak or illness that would cause every resident to itch or scratch. Personal Protective Equipment (PPE) such as gloves, gowns, and masks is made available for staff use but there was no reason to encourage staff/residents to use PPE or isolate in June of 2024. Wellness Director was interviewed and reported that residents are seen by a dermatologist anytime they experience a skin condition. LPA toured the facility and observed PPE including gloves, face masks, gowns and hairnets available in the facility. LPA also observed a sign posted in the facility encouraging the use of masks and hand sanitizer for those experiencing flu like symptoms. Regarding the allegation, “Staff did not provide adequate food service” it was alleged residents were served a meal that was not nutritious. This meal consisted of a chili cheese hot dog on a bun with potato chips and Kool-Aid to drink. It was reported that residents were also given water. LPA reviewed the facility's menu for June 2024 noting on 06/07/2024 a chili cheese dog, zucchini fries, and dessert were on the menu for lunch. However, the chili cheese dog was on the menu only one day out of the month and the menu listed a variety of foods. LPA conducted a witness interview with a dietitian who confirmed reviewing the facility’s menu and providing menu guidelines and consultative services to the facility monthly in the year 2024. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents reported the facility follows their menu, offers a variety of foods and drink options, or they can request alternative food options. The remaining two (2) residents were unable to provide information. Furthermore, it is not a requirement that the menu be posted in the facility. Regarding the allegation, “Staff did not provide a comfortable temperature” it was alleged a resident reported feeling warm and wanted the air to be on resulting in maintenance staff responding to the room to determine the issue. It was further alleged the vent in the resident’s room was observed to be closed, restricting the airflow. BOM Anguiano was interviewed and reported Resident 3 (R3) requests facility staff open and close the vent in their bedroom at various times. Therefore, the vent was closed at R3’s request and not due to facility staff malice or neglect. Administrator Mapilis was interviewed and reported R3 has complained about the temperature in their room and maintenance staff inspected the unit and reported there was nothing wrong with it. As a result, R3 has been offered to move to a different room or have a stand-up fan placed in their room. However, R3 has declined both offers. Mapilis reported that all thermostats are set to meet licensing regulations and maintain a comfortable temperature for all residents. R3 was interviewed and reported they instruct staff when to open and close their vent and staff have never opened or closed their vent without them asking. R3 was unable to recall an incident on 06/07/2024 regarding their vent. LPA toured R3s bedroom and observed all vents to be opened. LPA observed the hallway thermostat reportedly controlling R3s room set to 73-degrees Fahrenheit. Regarding the allegation, “Staff left resident unattended in direct sunlight without hydration” it was alleged a resident was left outside of the building in direct sunlight, unattended with no hydration. No further details were provided including the identification of the resident. BOM denied the allegations and it is believed the resident in question is Resident 4 (R4). R4 enjoys sitting in their wheelchair outside by the front door of the facility. However, R4 is always given a cup of water and facility staff constantly check on them. The Wellness Director reported that residents sitting outside are checked on after 30 minutes and encouraged to come inside. If they want to remain outside, the staff ensure they are appropriately dressed and provide fluids. An additional staff interview reported residents who choose to be outside are checked on at least every fifteen minutes. R4 was unable to participate in an interview. During a visit in September of 2025, this LPA observed R4 sitting in their wheelchair outside of the building, staff checking on R4 and encouraging R4 to drink from a cup that was provided. Regarding the allegation, “Staff did not meet resident’s medical needs” it was alleged a resident had a catheter. No additional details were obtained. The resident was only identified by their gender and the building they resided in. One (1) of five (5) staff interviewed reported they recall a resident with a catheter to reside in the respective building. However, they were unable to identify the resident. The remaining (4) of five (5) staff interviewed identified Resident 5 (R5) as the only resident to fit the description and use a catheter. They reported R5 receives home health assistance to change their catheter and have the capacity to independently empty it. R5 was interviewed and corroborated the information provided by the four (4) staff. LPA reviewed R5’s physician’s report dated 05/28/2024 noting they are ambulatory and do not exhibit memory loss. R5 did not report any issues or concerns with the catheter care. It was also alleged that R1 had a dirty and seeping bandage. Five (5) of five (5) staff interviewed reported that a dirty and seeping bandage never exited on any resident in the facility. The LPA was not able to interview all relevant parties which included a possible witness who may have observed any of the allegations during their visit. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report and Confidential Names list (LIC 811) were reviewed and provided to Administrator Mapilis. Regarding the allegation, “Staff did not ensure that the call light was accessible to residents” it was alleged residents are not aware of the call light or how to use it. It was further alleged the call lights were out of the resident’s reach and some were found behind the headboard of the bed. LPA toured several resident rooms and observed each call light to be accessible with the alarm pull cord lying on each resident’s bed. LPA observed some resident rooms with bed headboards. However, LPA did not observe any of the call lights behind the headboards. During the tour, a staff activated the call light and LPA observed it sounded an alarm at the resident’s front door, and the call light was manually turned off by staff. Three (3) of three (3) staff interviewed reported staff monitor all residents including those who are cognitively impaired and unable to use the call light system. Three (3) of three (3) staff interviewed reported facility staff added a small stuffed animal at the end of the pull cord so that the residents can easily locate the pull cord. One staff reported that caregivers check on all residents at least every two (2) hours to inquire if assistance is needed. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents reported their call light is accessible. The remaining two residents were unable to provide information. Regarding the allegation, “Staff did not ensure that the facility was kept clean” it was alleged soiled diapers were found in rooms in the exposed trash can. LPA toured several resident rooms and did not observe any soiled diapers in exposed trash cans. A staff interview conducted reported that staff are trained to promptly remove and dispose of soiled diapers after providing incontinent care to maintain a sanitary and odor free environment. The staff interviewed added caregivers are trained to place wet/soiled diapers in a trash bag and immediately dispose of the bag by placing it in a trash bin outside of the facility. A random sampling of 4 residents were interviewed. Two (2) of four (4) residents qualified for an interview reported housekeeping staff is constantly cleaning the facility and they have not observed wet/soiled diapers in exposed trashcans. The remaining two residents were unable to provide information.