complaint·December 17, 2025

The investigation consisted of the following: During the initial visit conducted on 06/17/2022, LPA Chinwe Nwogene toured the facility, interviewed staff 1-staff 4 (S1-S4), reviewed resident files, and collected pertinent documents. On 10/25/2025 LPA Gutierrez interviewed Executive Director by telephone, S5 by telephone, attempted phone interview with S6 and S7 in person, and residents 2- residents 10 (R2-R10). LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports, monthly responsibility personal care rate document, functional needs/service plan, identification information (LIC 601), and face sheet. During today’s visit LPA delivered findings. In regard to the allegation” Facility failed to check on the safety of resident”, It is alleged that after three days of calling R1 with no answer family went to facility and found R1 on floor and had to tell staff for help. During interview with Executive Director, staff three (3) out of seven (7) stated that R1 required no level of care and was independent. Executive director stated that meal checks are the only way to check on residents for the day and that the meal checks have not being done properly in the past. S3 stated that R1 was marked as refused on 06/09/2002 and 06/10/2022 because he/she did not see R1 at mealtime and assumed R1 did not want to eat. S4 stated they were responsible for verifying and signing off the meal attendance report but had not been doing that. During interviews with residents nine (9) out of ten (10) stated that staff comes and checks on them. R2 stated it may take them awhile, but they come eventually. Despite more than one staff knowing that R1 missed meals for 2 days there is no evidence that staff went to check on R1. Based on record review and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Crissy Pan