complaint·April 20, 2026

Allegation #1: Due to lack of supervision, resident was physically attacked by another resident. The complaint alleged that one resident attacked another by hitting the other and throwing the victim's TV against the wall. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation. The ED stated that when a resident exhibits aggressive behavior, they are typically removed from the situation and redirected to their seats or rooms. The department also interviewed the Administrator (A1), who also denied the allegation. A1 explained that this is a memory care facility, where they are aware of a resident who may have shown signs of aggressive behavior. However, they have sufficient staff to help redirect residents, and staff are always present near them. Additionally, the department interviewed four staff members (S1-S4), all of whom denied the allegation. They stated they are familiar with their residents and emphasized that such incidents are rare. The department also interviewed six residents (R1-R6), all of whom reported that no other residents had hit them. On April 16, 2026, the department reviewed the facility's daily notes for residents; none indicated that any residents were struck by others. No Unusual Incident Report was submitted to the Community Care Licensing Department. On April 17, 2026, the department interviewed the witness (W), who stated that whenever they visit the facility, they see many caregivers around the residents' rooms or nearby, supervising the residents. 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. Allegation #2: Staff hit resident. The complaint also alleged that a staff member hit the resident on multiple occasions, and there may have been bruising on the resident's arm. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that staff would not hit any residents because they knew they would be fired and reported to Law Enforcement. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that they would fire the staff and send an Unusual Incident Report to Community Care Licensing, the Ombudsman, family members, and Law Enforcement. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that they had never witnessed any staff member hitting a resident or that the resident had told them a staff member had hit them. The department interviewed six residents (R1-R6), all of whom denied being hit by staff members. On April 16, 2026, the department reviewed the facility's daily notes for residents, which did not document any incidents of staff members hitting residents. Additionally, no Unusual Incident Reports have been submitted to the Community Care Licensing Department. (CCLD) On April 17, 2026, the department interviewed a witness (W), who also denied the allegations. The witness (W) stated that this facility is the best place for R1 and expressed confidence that no staff member would harm R1. 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. Allegation #3: Staff serve food that is not of good quality. The complaint alleged that a resident has not been properly fed, receives cold, unappetizing food, and must beg for meals. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegations. The ED stated that the facility employs a dietitian with 10 years of service and that the facility provides a weekly menu, serving residents three meals a day. During the same time, the department also interviewed the Administrator (A1), who likewise denied the allegations. A1 stated that the facility serves a variety of high-quality meals to residents. The department then interviewed four staff members (S1-S4), all of whom also denied the claims. S1 explained that when preparing food, they accommodate residents' dietary needs as directed by doctors. S1 also noted that the weekly menu offers a diverse selection of dishes. If a resident doesn't like what is served, they can request an alternative. The department interviewed six residents (R1-R6), all of whom described the food positively. Four of the six reported that they had requested a second plate because they enjoyed the food, and they were always provided with one. On April 16, 2026, the department toured the kitchen while lunch was being prepared. The department also observed a variety of dishes, including Vegetable Medley Soup, Ham and Cheese Macaroni Bake, a green salad, fresh fruit, and Blueberry French Toast. On April 17, 2026, the department interviewed a witness (W) who stated that when visiting R1, (W) observed that the meals served were very good. 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 Administrator Liliana Moreno.