complaint·December 3, 2025

It was alleged staff are restraining residents. According to the information received, staff are placing weighted vests on residents to keep them immobile. LPA toured and thoroughly searched interior and exterior of the facility but was unable to locate any weighted vest or anything like it. LPA did not observe anything used to physically restrain residents. LPA conducted interviews with two (2) residents, both of whom stated that they have never seen weighted vests or experienced any form of restraint. LPA conducted interviews with two (2) residents’ responsible persons, all of whom denied seeing residents wearing weighted vests or any form of restraint. LPA conducted interviews with two (2) staff members, both of whom denied ever using any form of restraint or weighted vests on residents. Based on interviews conducted and observations, there is insufficient evidence to support the allegation that staff are restraining residents. This allegation is unsubstantiated . It was alleged staff are providing THC drinks/protein powder to residents without a physician’s order. According to the information received, staff are serving THC drinks to keep residents sedated and are giving protein drinks without doctor’s order. LPA conducted a tour of interior and exterior of the facility and observed THC drinks in the facility refrigerator. LPA also observed nutritional supplements in both liquid and powder forms in the facility kitchen pantry. LPA’s record review revealed that both residents had doctors’ orders for THC drinks and nutritional supplements. LPA conducted interviews with two (2) residents, but none of them knew if they consume THC drinks or nutritional supplements. LPA conducted interviews with two (2) residents’ responsible persons, both of whom acknowledged that residents consumed THC drinks and nutritional supplements. LPA conducted interviews with two (2) staff members, both of whom confirmed that both residents had doctors’ orders for THC drinks and nutritional supplements. Based on interviews conducted and observations, there is insufficient evidence to support the allegation that staff are providing THC drinks/protein powder to residents without a physician’s order. This allegation is unsubstantiated . It was alleged residents are charged for services not rendered. LPA conducted interviews with two (2) residents’ responsible persons, both of whom denied being charged for services or goods not provided. LPA conducted an interview with the Administrator who stated that the only extra charges would be for services like haircut, podiatry services, or incontinence care supplies. LPA’s review of the admission agreement revealed each resident receives basic care services and their charges are aligned with the basic level services. Based on interviews conducted and file review, there is insufficient evidence to support the allegation that residents are charged for services not rendered. This allegation is unsubstantiated . Continued on LIC9099-C.... It was alleged residents are left unattended. According to the information received, the Administrator frequently leaves the residents alone at night. LPA’s interview with two (2) staff members revealed the facility has live-in caregiver (S1). LPA’s review of staff schedule and S1’s live-in employment agreement corroborated the staff members’ statements. LPA did not observe any gaps in the staff schedule. Both staff members denied ever leaving the residents in care unattended. LPA conducted interviews with two (2) residents, all of whom stated there are staff members present throughout the day and night. LPA conducted two (2) residents’ responsible persons, all of whom stated there were staff members present whenever they visited. LPAs conducted nighttime visit and observed staff members were present at the facility. Based on interviews conducted and record review, there is insufficient evidence to support the allegation that residents are left unattended. This allegation is unsubstantiated . It was alleged staff put up bed rails without physician’s orders. LPA observed one (1) resident with full bedrails and another resident with half bedrails. LPA’s file review revealed both residents had doctors’ orders for their bedrails. Based on interviews conducted and record review, there is insufficient evidence to support the allegation that staff put up bed rails without physician’s orders. This allegation is unsubstantiated . Based on records review, resident interviews, and staff interviews, above allegations are Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided. It was alleged staff are restricting visiting hours. According to the information received, there is a visiting hour posted at the facility door, and visitors must call before visiting. During the tour of the facility, LPA observed a sign at the facility door showing visiting hours of 10:00 AM to 6:00 PM. The sign also showed requirement for visitors to obtain approval for visitation during mealtimes. LPA conducted interviews with two (2) residents’ responsible persons, both of whom denied experiencing any restriction with visitation. However, the two (2) responsible persons stated they usually call the Licensee if they were visiting outside the posted visiting hours. LPA conducted interviews with two (2) staff members, both of whom stated no visitors have been denied entry to the facility outside of the visiting hours if the visitors get approval from the Licensee. Based on the interviews conducted and observation, there is sufficient evidence to support the allegation that staff are restricting visiting hours. This allegation is substantiated . It was alleged residents moved to other facilities without consent. According to the information received, the Administrator moves the residents around between the two facilities owned by the same Licensee. LPA’s interviews with two (2) residents revealed that the Administrator moves one (1) of the two (2) residents to Desert Cottage (facility #336423671) during daytime for activities. LPA conducted an interview with the Administrator who acknowledged that they moved one (1) of the two (2) residents to other facility for activities. However, the Administrator stated they did not have written agreement from the resident’s responsible person. Based on interviews conducted, there is sufficient evidence to support the allegation that residents moved to other facilities without consent is substantiated . A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099C, LIC9099D, and Appeal Rights were provided. ***LPA Seo Jeon conducted subsequent visit to deliver amended LIC9099-D with new plan of correction.