Complaint·September 16, 2025

22 CCR Section 87412(h) requires personnel records to be maintained for at least three years following termination of employment. Additionally, 22 CCR Section 87411(c)(6) requires the licensee to "maintain documentation pertaining to staff training in the personnel records..." LPA Moleski reviewed R1's LIC 602, dated 11/10/23, prior to R1's admission date of 12/6/23. LPA Moleski observed that many fields of required information, including information regarding any potential medically ordered restricted diets, were not completed. The LIC 602 indicated there was an "additional patient response" form attached to the LIC 602 with the information. This additional patient response form was not included in R1's file. LPA Moleski asked Boboc if she had a copy of the patient response form. Boboc said she never had a copy of the patient response form. LPA Moleski pointed out that she had accepted a resident without full information regarding their medical needs. Boboc acknowledged this and said she was not aware of this at the time. Without a physician's order on file, licensees, staff, or attorneys-in-fact may not restrict a resident's right to personal preferences regarding meals. However, in interviews, Boboc said they had restricted R1's diet at the request of R1's attorney-in-fact (R1's RP). Boboc said this was distressing to R1, who did not understand why they could not eat what other residents were eating. In an interview, R1 voiced no concerns with the quality of food served at this facility. In interviews, both R1 and R1's RP said that staff had removed decorations from R1's room. R1 said that staff "tore" the decorations down. In an interview, Boboc said she didn't know what had happened, as she was not present. LPA Moleski was unable to contact the staff person who was working at the time. Boboc said she did not know who was on duty at the time. S3 said that they started working at the facility after S4 left, around late December 2024 or early January 2025, and at that point, the decorations had been put back up. This facility does not keep daily medication administration records. LPA Moleski performed an audit of medications during this visit, and observed physician's orders were not being followed. LPA Moleski observed a blood pressure medication, one tablet of which was to be given twice daily, unless blood pressure was too low or unless heart rate was below 55. LPA Moleski observed a start date for this medication of 9/6/25. LPA Moleski counted out the remaining tablets and observed that the medication had consistently been given twice daily since that date. However, LPA Moleski observed several days since that date wherein R1's heart rate was recorded below 55, meaning that the medication should have been held per the prescription orders. [continued on 9099-C] Although the licensee should have sought to acquire all pertinent medical information before admission, they cannot be held accountable for adhering to physician's orders which they were not provided. LPA Moleski will address the licensee's failure to acquire this crucial medical information in a separate case management report. LPA Moleski reviewed R1's admission agreement. LPA Moleski observed numerous modifications in this agreement made by R1's RP. Boboc signed the agreement, which makes all modifications enforceable. However, LPA Moleski did not observe any such provision, modified or otherwise, which would require that only female staff provide care for R1. However, LPA Moleski observed that R1's resident appraisal, signed by Boboc on 12/15/23, does indicate that R1 shall have "female staff only -- especially for intimate care." In an interview, R1 said they are only cared for by female staff. In interviews, S1-S3 said that R1 is only cared for by female staff. In an interview on 1/9/25, R1 said that staff are not harassing them, and said that staff do not speak inappropriately to them. R1 said that they regularly receive showers twice per week. R1 said they can "holler" for staff if they need assistance at night, but they don't always ask for it. R1 voiced no concerns with the quality of food served in this facility. In an interview on 9/16/25, R1 said that they are not changed frequently enough. However, R1 also said all their needs were being met and said that they do not always let staff know when they need assistance with diaper changes. LPA Moleski reviewed R1's functional capabilities assessment, dated December 2023, and observed that R1 is fully able to express themselves verbally, and has some bladder and bowel control. R1's LIC 602, dated 11/6/23, indicates that R1 does not suffer from mild cognitive impairment or dementia. R1's preadmission appraisal, dated December 2023, does not indicate that R1 needs special overnight supervision. In interviews, S1-S3 said they had not witnessed any sort of harassment or inappropriate comments being made toward R1. In interviews, the other residents of this facility, R2-R5, did not voice any concerns regarding medications, harassment, inappropriate comments, showers, or diaper changes. R2, who does not have a dementia diagnosis, said that their diapers are changed as frequently as necessary, and said that they are able to get nighttime assistance without issues. LPA Moleski observed that, starting in June, facility staff began documenting R1's daily care to ensure consistency. During this visit, all residents appeared clean and cared for. [continued on 9099-C] The department has determined the following as it relates to the allegations that staff are not abiding by a resident's admissions agreement, that staff are making inappropriate comments towards a resident, that staff are harassing a resident, that staff did not ensure a resident was showered, that staff left a resident in a soiled diaper for an extended period of time, and that staff are not following a resident's dietary needs: Based on interviews, observations, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Boboc. The department has determined the following as it relates to the allegations that untrained staff are providing care to a resident, that staff are not providing adequate food service to a resident, that staff did not safeguard a resident's personal belongings, and that staff are mismanaging a resident's medication Based on interviews, observation, record review the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87555(b)(5), 87411(c)(6), 87217(b), and 87465(a)(4). An exit interview was held with Boboc. Appeal rights and a copy of this report were left with Boboc.