complaint·April 17, 2026

Allegation #1: Staff do not meet residents’ incontinence needs. The complaint alleged that residents' briefs were changed late and that this caused rashes. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the caregiver changed residents' diapers every two hours and as needed. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that caregivers changed residents' diapers every two hours and as needed. A1 also stated that if a resident needed to be changed sooner, the caregiver or any staff member would do so. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that they know their residents and how often they need to be changed. Additionally, the department interviewed 6 residents (R1-R6), 4 of whom wear diapers, and none reported that the caregiver took too long to change them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Report Continue on LIC9099C Allegation #2: Staff do not ensure residents are bathed. The complaint also alleged insufficient time for showers and that residents are not receiving them when they should. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the facility maintains a shower schedule for all residents, including those in hospice. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that residents are showered three times a week, with some showering every day if they choose. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that residents have scheduled showers, with some showering three times a week or every day. Additionally, the department interviewed 6 residents (R1-R6), all of whom reported showering regularly but sometimes not wanting to shower. On April 16, 2026, the department reviewed the facility’s residents' weekly shower schedules, which showed that most residents are scheduled three times a week, and hospice residents are scheduled three times a week as well. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Report Continued on LIC9099C Allegation #3: Staff do not maintain the facility in clean and sanitary condition. The complaint alleged that there are no housekeeping services on weekends and that, upon arrival, visitors often report that the facility is generally not clean. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the facility has caregivers and housekeepers on weekends. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that the facility schedules three to four housekeepers on weekends. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that the facility schedules housekeepers on weekends because residents' rooms need to be cleaned then. Additionally, the department interviewed 6 residents (R1-R6), all of whom stated that their rooms are cleaned on weekends as well. They also stated that if they spill something, the housekeeper cleans it right away. On April 16, 2026, the department toured the facility and some residents' rooms. The rooms were clean, and the facility did not appear to be in disrepair. The department observed that the housekeeper was mapping the residents' floor while the residents were outside. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An Exit interview was conducted, and a copy of this report was provided to the Executive Director, Valerie Garcia.