complaint·March 5, 2026

An interview with Additional Witness 1 (AW1) revealed that during a family visit with R1, relatives reported to AW1 that R1’s appearance and hygiene were poor. AW1 stated staff were informed that R1 had been refusing to bathe and staff were only able to encourage proper hygiene practices, but could not force R1 to comply. Interview with Executive Director Teresa Mipilis revealed that R1 began to refuse showers despite multiple attempts by various caregiver encouragement. ED reported that R1’s Responsible Party (RP) was notified verbally of the refusals and they acknowledged R1’s decline. ED noted that RP was informed that R1 was not maintaining hygiene and becoming increasingly withdrawn. An interview with Staff 1 (S1) revealed that R1 frequently refused assistance with showering or bathing, often insisting they could do it themselves or declining bathing entirely. S1 reported that each refusal prompts three separate attempts by staff to encourage R1 to maintain their hygiene. Interview with Staff 2 (S2) revealed that R1 refused to shave and did not allow staff to trim their beard for over two months. S2 reported that R1’s RP was informed of the ongoing hygiene refusals and acknowledged the concern. Interviews with three out of three residents corroborated that they receive sufficient hygiene assistance from facility staff. R2 added that they appreciate being allowed to bathe independently and upon request, assistance from staff. A review of records obtained revealed chart notes from 2023 through 2025 documented multiple instances in which R1 refused Activities of Daily Living (ADL’s) on various dates and times. Additionally, documents obtained revealed R1’s assessments and care plans were updated over time to gradually increase the level of staff assistance provided for hygiene care. A review of Title 22 under the California Code of Regulation was conducted, information obtained under Personal Rights revealed that Section 87468.2(a)(6) references the residents right to make choices concerning their daily lives at the facility. For the allegation that staff did not meet a resident’s dental needs, it was alleged that on December 10, 2024, the facility received an order for oral surgery for R1 and subsequently failed to ensure that R1 was sent to the scheduled dental procedure. An interview with AW1 revealed they were informed the facility had an in-house dentist. AW1 was unsure how many times R1 had been seen, due to staff not providing updates. An interview with Staff 3 (S3) revealed they assisted R1 with dental appointments and confirmed that R1 received seven dental treatments, including an oral surgery completed on December 10, 2024. A review of R1’s records showed documented dental treatments on the following dates: 10/20/2023, 03/27/2024, 05/29/2024, 08/17/2024, 11/20/2024, and 12/10/2024. Continued on LIC 9099-C. For the allegation that staff did not conduct a reassessment for a resident, it was alleged that R1 experienced a cognitive decline and the facility failed to complete appropriate reassessments in response to the change in condition. An interview with AW1 revealed concern regarding R1’s declining cognitive behaviors and noted that AW1 frequently requested that the facility perform a reassessment. AW1 added that the reassessment was necessary to obtain additional support services, such as home health. AW1 stated they were unaware whether reassessments had been completed, because the facility did not provide updates. An interview with the Executive Director confirmed that multiple reassessments and care plans for R1 was completed. An interview with Staff 4 (S4) further noted the facility conducted reassessments and provided updated care plans to RP, obtaining digital signatures acknowledging receipt on multiple care plans. A review of records showed that medical reassessments for R1 were completed on 7/26/2023, 9/20/2023, 3/27/2024, 11/6/2024, and 12/30/2024. Based on interviews, research, and record review, the allegations that facility staff did not meet a resident's hygiene needs, staff did not meet a resident's dental needs, and staff did not conduct a reassessment for a resident is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Teresa Mapilis.