Complaint·August 20, 2025

R1’s admission agreement dated 05/31/2022 was reviewed and revealed R1 was a private pay resident being charged $2500 a month. Staff reported R1 was previously participating in a program that did not continue after the change of ownership. Staff reported that residents participating in this program were given the option to work with the program to identify new facilities contracted with that program so R1 could continue to receive the benefits of that program. Staff report R1 chose to remain in the facility and enroll in the ALW program. LPA reviewed the ALW Patient’s Rights, Freedom of Choice Form, and Amenity Form dated in October of 2023 reflecting R1’s signatures and acknowledging awareness to the ALW participant’s role and responsibility. Due to R1 declining to provide any additional information, LPA was unable to confirm R1’s signature to validate the ALW program consent forms, or to validate if they were pressured to participate in the ALW program. Staff reported R1 was required to pay their portion of the agreed upon rate and the ALW program would pay another portion. Staff reported R1 was not paying their portion of the agreed upon rate. LPA was unable to confirm with R1 if payments were being made or not. LPA received a copy from the facility of an unlawful detainer issued for R1. Therefore, this allegation is unsubstantiated. Regarding the allegation, “Food service is not provided in a timely manner to residents in care” it was alleged food is served late or not at all. LPA made contact with the reporting party who was unable to identify the affected residents nor provide additional details. As a result, LPA conducted an interview with a sample of the population. Facility staff was interviewed and refuted the allegation. Staff reported breakfast is served from 7:30 a.m. to 9:00 a.m., lunch from 11:45 a.m. to 1:00 p.m., and dinner from 4:45 p.m. to 6:00 p.m. Eight (8) residents were interviewed, and eight (8) of eight (8) reported meals are served in a timely manner. Therefore, this allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was reviewed and provided to Wellness Coordinator Jones. Regarding the allegation, “Staff do not ensure residents dietary plan is followed” it was alleged Resident 2 (R2) requires a diabetic diet, and the facility does not accommodate them. R2 was interviewed and corroborated the allegation. However, LPA reviewed R2’s physician’s report and the “Other Conditions” section states, “DM II” but the "Special Diet" subsection is marked "No". A staff interview conducted reported certain residents prescribed diabetes medications may not require a special diet, as some medications require a regular diet to prevent dangerously low blood sugar levels. The staff showed LPA R2’s physician’s orders and reported it listed a prescription medication commonly used to help manage type 2 diabetes. LPA made several unsuccessful attempts to contact the physician listed in R2’s physician’s report to confirm whether R2 required a special diet. Staff reported R2 would tell them, they could not consume sugary foods however, R2 is known to request high-sugar desserts such as chocolate cake with meals. The facility reported they never received an updated physician’s report or medical record to indicate R2 ever required a special diet while they resided in the facility. A staff interview conducted reported R2 has since moved out of the facility and there is no forwarding contact information for them. Therefore, this allegation is unsubstantiated. One (1) of four (4) residents interviewed corroborated the allegation. Three (3) of four (4) residents interviewed reported although they have experienced issues with bed bugs or roaches in their rooms, a professional pest control company treated their rooms promptly. However, LPA reviewed the facility’s pest observations log which noted on 3/8/2024 and 3/27/2024, three (3) resident rooms were identified to have sightings of bedbugs/roaches and the log's “Corrective Actions Taken” column was left blank. LPA conducted a witness interview with Orkin who reported there is no documentation that the three (3) resident rooms identified in the pest observations log and the additional resident room identified during the resident interviews received treatment on or around the reported dates. Administrator Bowie reported during the identified incident time-frames, the facility did not work with any other pest control company besides Orkin. Facility staff was unable to provide documentation to demonstrate the facility took appropriate action to mitigate the pest sightings reported in the specific resident rooms. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore this allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report, LIC 9099-D, and Appeal Rights were reviewed and provided to Wellness Coordinator Jones. Administrator Molly Bowie called Wellness Coordinator Jones and implemented the plan of correction with LPA.