Complaint·October 23, 2025

LPA Moleski interviewed Cuevas, nine staff members of this facility, and three non-staff witnesses, comprised of one resident’s family member, another resident’s friend, and an ombudsperson. In interviews, multiple staff members said that the blue-and-black chairs were lightweight, flimsy, and posed a hazard to residents in care. In an interview, Cuevas described the chairs as “lightweight,” and said that some residents were pushing the chairs back when they stood up. S1 said the chairs were replaced due to falls and due to questions of sturdiness. S1 said the chairs had a tendency to “go back,” and residents needed something sturdy. S1 said that R1 plops down heavily when they sit, and they also rock when standing up. S1 said they had observed the chairs moving around when residents rocked in them. S1 said they had concerns about the safety of the chairs. S2 said the chairs had a tendency to rock, and described them as “a bit shaky” and not “that sturdy.” S3 said the chairs were wobbly. “Anything that’s wobbly is going to be unsafe for a senior,” S3 said. S5 said that the chairs might have been unsafe. S5 said the chairs were thin, and residents tend to slam down when they sit. S5 said they had observed the chairs tipping back when residents sat down. S7 said there may have been a fall risk posed by the chairs. S7 said the chairs were very light and thin, which meant residents sitting down heavily might tip their chairs back. S7 said that R2 did have a habit of sitting down hard. S3, S4, S5, and S7 said they responded to R1’s fall as described above. S3, S4, S5 said R1 was either trying to stand up from a chair or sit down into one, although they did not witness the fall. S7 said that when they responded, they observed R1 lying back up against a window pane. S7 said it appeared that R1 had fallen backward out of the chair. S2 said they responded to R2’s fall as described above. S2 said that, upon arrival, they observed R2 on the floor propping themselves up. S2 said it appeared that R2’s chair had tipped backward. In interviews, multiple staff members were aware that loose screws had been falling out of the chairs (S1, S2, S3, S4). According to S1, screws started coming out of the chairs about a month after the chairs were first put out. In a previous interview, S1 told LPA Moleski the chairs were put out around the middle of May. In a previous interview, S1 told LPA Arielle Pascua that screws were coming out of the chairs daily. S1 told LPA Moleski that maintenance staff were re-tightening the screws. [continued on 9099-C] S2 said that any chairs that were losing screws were removed when they were noticed. S4 said that maintenance staff were reinforcing the chairs with loose screws. In interviews, visitors of this facility voiced concerns over the patio chairs. A resident’s family member said they had observed wobbly chairs and chairs with missing screws, which they removed from the area. A different resident’s friend had observed screws coming loose from chairs, which maintenance staff screwed back into the chairs. On one occasion, chairs with loose screws were removed from the area when brought to the attention of staff, according to the resident's friend. The resident’s friend had also observed the chairs wobbling and/or tipping when residents sat down heavily into them. Based on the above, facility staff were aware of issues with the blue-and-black model of chair which were used in the memory care patio area between approximately mid-May and late August 2025. These issues included a tendency for the chairs to tip and/or wobble when residents sat down into them and a tendency for the chairs to lose screws. Although some staff reported that chairs with loose screws were reinforced by maintenance or removed from the patio area, at least two visitors independently discovered screws coming loose from chairs. Despite these known issues, the blue-and-black chairs remained available to residents for more than three months. The department has determined the following as it relates to the allegation that unsafe furniture was present in the memory care patio area: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87303(a). An exit interview was held with Cuevas. Appeal rights and a copy of this report were left with Cuevas.