Complaint·June 11, 2026

“Resident sustained an injury due to staff neglect or physical abuse.” It was alleged Resident #1 (R1) was also observed with scratches on the inner part of their arm and a small bruise on their wrist. It is unknown how R1 sustained these injuries. There were no additional details or photos provided of the alleged injuries. LPA conducted (2) staff interviews with staff who work with R1 12/23/2025 and 12/25/2025. (2) of (2) staff revealed that they did not recalling seeing any injuries on R1’s arm or wrist. LPA attempted to conducted an interview with R1, however R1 was not alert or oriented during the interview. LPA conducted an interview with R1’s responsible person who reported that they had previously observed scratches on R1’s face. LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated they had no concerns about resident abuse or neglect, and were unaware of any residents being injured on their arms and wrist. LPA conducted records review of charting notes for R1 from 12/23/2025 to 12/25/2025 and found no charting notes for R1 on those dates. LPA conducted records review and staff interviews which revealed there were no incidents reported for R1 from 12/23/2025 to 12/25/2025. Therefore, the allegation that R1 had observed scratches and bruises was found to be unsubstantiated. “Resident left in soiled linens/bed for an extended period.” It was alleged that on 12/23/2025 and 12/25/2025, R1 was found lying in their bed which was saturated with urine. LPA conducted (2) staff interviews of staff who work with R1. (2) of (2) staff revealed that R1 would refuse to be changed when they were soiled with urine. Both staff stated that R1 would refuse to be changed and would conduct attempts to change R1 with different staff at different times. Both staff were unaware of a time when the bedding was saturated with R1’s urine. Both staff reported R1 is changed every (2) hours. LPA conducted an interview with R1’s responsible person who stated that they had observed R1’s bedding with urine on several occasions. R1’s responsible party stated it R1 had a large amount of urine which soaked their bedding. R1’s responsible party stated staff would report that R1 was changed (2) to (3) hours ago. LPA conducted observations of R1’s bedding and bed on 06/08/2026 and 06/11/2026 and observed R1’s bedding was dry and did not smell of urine. Therefore, based on interviews and observations the allegation that R1 was left in soiled linens for an extended period of time is unsubstantiated. “Staff did not ensure resident was accorded a comfortable room temperature.” It was alleged that on 12/23/2025 and 12/25/2025 R1’s window was left partially open which caused the room to be uncomfortably cold for R1. LPA conducted (2) staff interviews with staff who work with R1, who stated they did not recall a time when R1’s window was left open causing their room to be uncomfortably cold. Both staff reported staff open R1’s and other resident’s windows occasionally and will conduct checks on resident’s rooms to close the windows when necessary. LPA conducted an observation of R1’s room on 06/08/2026 and 06/11/2026 and did not observe R1’s window open. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s room was uncomfortably cold. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated their rooms are kept at comfortable temperatures. Therefore, the allegation that R1’s room was not kept at a comfortable temperature is unsubstantiated. “Staff are not providing adequate laundry service.” It was alleged that for a week prior to 12/23/2025 and 12/25/2025 R1’s clothing had not been laundered in over a week. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s laundry was not done for over a week. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated their laundry is conducted regularly by staff and is conducted once or twice a week. LPA conducted (2) staff interviews with staff who work with R1, who stated that resident laundry is conducted twice weekly and as needed. Both staff denied their was an instance where R1’s laundry was not conducted over a week. Therefore, the allegation that staff did not laundry R1’s clothing for a week is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided. *LPA was offsite from 11:30am to 1:00pm. “Staff are not meeting the resident's incontinence needs.” It was alleged that on 12/23/2025 and 12/25/2025, R1 was found lying saturated in their urine by a visitor. It was further alleged that a staff reported to the visitor that R1 refused to be changed. LPA made attempts to contact the visitor however, they were unavailable for interview. LPA conducted (6) resident interviews and (4) staff interviews which revealed that there is no staff matching the name provided by the visitor. LPA reviewed the staff roster and identified Staff #1 (S1) with a name similar to the staff name mentioned in the allegation. LPA conducted (4) staff interviews, including S1. Four (4) of four (4) staff revealed that S1 does not work with R1. Three (3) of four (4) staff revealed that R1 would refuse to be changed when they were soiled during the initial transition period after being admitted to the facility. Three (3) staff revealed they would conduct attempts to change R1 with different staff at different times, and also by calling R1’s responsible party to assist in changing or redirecting R1. Three (3) staff stated R1 was checked on every (2) hours and as needed to change their brief. Three (3) staff revealed that R1’s responsible party and doctor were notified of R1 refusing to be changed. Three (3) staff revealed that R1 is now receptive to staff changing R1’s brief and have no issues changing R1. LPA interviewed R1’s responsible person who stated staff would inform them of R1’s refusals when they first admitted to the facility, but have not been informed recently on R1’s refusals. R1’s responsible party stated that they have continued to observe R1 soiled in urine on different dates and different times when visiting R1 at the facility. R1’s responsible party stated staff would report that R1 was changed (2) to (3) hours ago. LPA made attempts to interview R1’s Physician and Physician’s Assistant, however they were unavailable for interview. LPA attempted to interview R1, however R1 was not alert or oriented. Therefore, based on interviews and records review the allegation is substantiated. “Staff did not ensure resident receive scheduled showers.” It was alleged R1 had not taken a shower in over a week. LPA attempted to conduct an interview with R1, however they were not alert or oriented. LPA conducted an interview with R1’s responsible party who revealed they were not aware of a time where R1’s had not taken a shower in over a week. R1 does not have a roommate LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. Six (6) of six (6) residents stated they receive showers twice a week and observe staff giving other residents showers. LPA conducted two (2) staff interviews with staff who work with R1. One (1) staff was unaware of a time where R1 was not showering for over a week. One (1) staff revealed that they recalled a time where R1 did not shower for a week due to them refusing to shower and notified R1’s responsible party and physician of the refusals. Staff revealed resident refusals to shower were not documented. LPA reviewed R1’s charting notes for December 2025 which revealed no documented refusal for showers. LPA conducted attempts to interview R1’s physician and physician’s assistant however they were unavailable for interview. Therefore, based on interviews and records review the allegations are substantiated. Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. *LPA was offsite from 11:30am to 1:00pm.