Complaint·September 30, 2025

It was alleged staff do not ensure medications are dispensed as prescribed. LPA reviewed medications and MARS and did not observe a preponderance of evidence that medications were not dispensed as prescribed. It was alleged staff did not ensure facility had a working water supply for residents in care. LPA observed there was working water supply in kitchen and both bathrooms. The facility provides drinking water via refrigerator water dispenser and sometimes provides bottled water. Based on observations and interviews the allegation that the facility does not have a working water supply for residents in care is unsubstantiated. It was alleged staff does not ensure bathrooms are kept in clean sanitary conditions. Based on observations, the bathroom was in clean condition. LPA observed staff cleaning the bathroom upon arrival on 9/4/2025. It was alleged staff do not ensure bathrooms are in good repair. Based on observations, the bathroom was in working conditions including the toilet, sink faucet, shower, and doors. There was no corroborating evidence to prove staff do not ensure bathrooms are in good repair. It was alleged staff has inappropriate personal conversations while in front of residents. Based on resident and staff interviews there was not a preponderance of evidence that staff has inappropriate personal conversations while in front of residents. It was alleged staff do not seek medical care for residents in a timely manner. Based on records review and interviews, there was no evidence to corroborate that staff do not seek medical care for residents in a timely manner. It was alleged staff discourage residents from filing complaints. Based on records review and interviews, there was no evidence to corroborate that staff discourage residents from filing complaints. It was alleged staff do not ensure adequate supervision is provided to residents. LPA observed two staff during each visit. Based on records review and interviews, there was no evidence to corroborate that staff did not ensure adequate supervision is provided to residents Based on the information gathered through observation and record reviewed, the preponderance of evidence requirement was not met, therefore the above allegations noted were UNSUBSTANTIATED. An exit interview was conducted with S4 and a copy of these LIC 809 reports were provided to the facility. LPA observed a live cockroach in the kitchen counter top when reviewing records. LPA observed cockroach traps in bedrooms, bathrooms, and kitchen areas. Staff and resident interviews confirm there are cockroaches in bathrooms and bedrooms which come out at night. Based on the observations of the LPA and review of resident records the allegation the allegation that do not ensure facility is free of pests is substantiated. On 9/30/25 LPAs observed cockroach on the floor located in the dining room. On 9/23/25, LPA Kevin Gould cited deficiency for regulation 87303(a) during a case management visit, in which the facility has agreed to provide a written cleaning and infection control schedule and provide a written plan of correction indicating how the facility will ensure the facility is kept clean. It was alleged that staff did not ensure that staff does not ensure adequate amounts of food is served to residents in care. LPA toured the kitchen pantry, refrigerator, and freezer inventory and observed. LPA observed there was not sufficient seven day non-perishable and two day perishable food supplies accounting for ten resident’s three meals a day along with utriculus snacks during this visit, on 8/28/25, and 9/4/2025. LPA observed there is no pre-planned menu available to resident’s. The posted sample menu is not followed. LPA observed grocery food deliveries were made on 8/22/25, 8/28/25, 9/4/25, and 9/8/2025, all dates in which Licensing staff and or Ombudsman conducted facility visits. Staff and resident’s stated they think there is not enough food at the facility. Staff stated they did not make dinner on 9/3/25 due to resident ordering and picking up three large pizzas for dinner which they paid for using their personal CalFresh benefits ($53.17) which was given to all residents. The facility Plan of operation states “Menus will offer a variety of dishes, taking into account the cultural and religious background and food habits of the residents … Menus are kept on file in the facility as served … The following menus represent appropriate food groups and portions for our residents … discussion with our residents, this menu may be revised to reflect their individual needs and desires while maintaining a balanced and nutritious diet. At all meals, or anytime, beverages are encouraged and available…”. Based on the observations of the LPA and review of records the staff the allegation that staff do not ensure facility is free of pests is substantiated. On 9/23/25, LPA Kevin Gould cited a deficiency for regulation 87555(b)(26) due to the facility does not have a 2 day perishable food supply to meet the needs of residents which poses an immediate health, safety and personal rights risk to residents in care. It was alleged that staff does not ensure night supervision is provided to residents. Staff stated there is no wake staff and they are upstairs at night time. Four residents stated R5 wonders around at night. Although R5’s appraisal indicated they do not require nighttime supervision, R5’s LIC 602 physicians report indicated they has is dementia diagnosis, "confused and disoriented sun downing behavior and is at risk"; R5’s LIC 602 is was completed over 12 months ago and is in need of a re-evaluation. Continued on 809-C Based on the observations of the LPA and review of records the staff allegation that does not ensure night supervision is provided to resident is substantiated. It was alleged that staff do not prevent residents from entering other residents’ rooms. 5 of 10 residents stated R5 goes into other resident bedrooms. On 9/4/25 and 9/8/25, LPA observed R5 going into other resident bedrooms without knocking first. LPA did not observe any redirection from staff. Based on the observations of the LPA and review of resident records the allegation that Staff do not prevent residents from entering other residents rooms is substantiated. It was alleged that staff do not ensure reporting requirements are followed. Per record review and interviews, the facility did not submit incident reports (SIR) to the regional office for hospitalization that occurred for R4 on 7/11/25 and 9/1/25 and R3 on 8/29/25. Staff stated they informed R4’s family regarding their high blood pressure and emergency hospital transport being called on 9/1/25 but did not have information regarding the other dates. Based on the observations of the LPA and review of resident records the allegation that Staff do not ensure reporting requirements are followed is substantiated. It was alleged that staff do not ensure meals are properly prepared for residents in care. 5 out of 10 residents stated there is not enough food and the quality of food is low as of the last 1-2 months. Record review indicates there are special diets that staff is not aware of. Staff stated Menu’s are not created in advance and are decided based on food inventory the day of or the day before. LPA did not see enough food or vegetables available on 9/4/25 and 9/8/25. LPA observed some breads were burnt and served to residents on 9/4/25. On 9/8/25, LPA observed an egg carton containing 60 eggs with a label that read “keep refrigerated” were being stored in room temp pantry. The egg carted was purchased on 9/4/25 from Walmart. Record review shows there has not been any training regarding food preparation for S1, S2, and S4. Based on the observations of the LPA and review of resident records the allegation staff do not ensure meals are properly prepared for residents in care is substantiated. It was alleged that staff does not ensure residents are accorded personal privacy. 4 out of 10 resents stated R5 opens their door with out knocking often. LPA observed R5 opening the door to R4’s bedroom on 9/4/25. Based on the observations of the LPA and review of resident records the allegation that Staff does not ensure residents are accorded personal privacy is substantiated. continued on 809-C It was alleged that staff did not prevent other staff from consuming residents food. S1 admitted they and S2 each ate two slices from the food a resident purchased on 9/3/25 with their personal funds. Based on the observations of the LPA and review of resident records the allegation that staff did not prevent other staff from consuming residents food. is substantiated. Based on the information gathered through observation and record reviewed, the preponderance of evidence was met, therefore the above allegations noted were SUBSTSANTIATED. deficiencies were cited (See LIC809D reports). An exit interview was conducted with S4 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility. An exit interview was conducted with S4.