complaint·June 3, 2025

During a visit to this facility on 3/7/25, CCLD staff observed food which was improperly covered, insufficient food supplies, unclean refrigerators, and freezer burned food. In recent interviews, a resident (R1) said the facility’s food had been “poor quality” several months ago, but had since improved. LPA Moleski visited this facility during daytime hours on 5/5/25 for a period of approximately 6.5 hours. LPA Moleski visited this facility a second time during daytime hours on 5/20/25 for a period of approximately 5.5 hours. During these time periods, LPA Moleski did not observe most residents engaged in meaningful activities. LPA Moleski did observe one resident with dementia playing with sensory stimulation devices, but did not observe any other group or individual activities ongoing. Residents observed during these time periods were largely either watching television or sitting outside. LPA Moleski interviewed two residents who were able to coherently respond to questions and who were not diagnosed with any sort of cognitive impairments (R2 and R7). R2 said that there are board games at the facility, but they are not played. R2 did not identify any other activities that are available for residents. R2 said that activities are not possible due to the condition of the other residents of the facility. R7 also said there are games around the facility, but they are not used. R7 had not observed other residents engaged in meaningful activities. LPA Moleski interviewed a staff member (S3) on the same date LPA Moleski interviewed R7. S3 claimed that a board game had been played with residents the day before. In an interview, R6’s RP said that there was “not a lot of stimulation” at the facility, that staff “don’t seem to engage them in activities,” and that when they visit, R6 is typically watching television. The department has determined the following as it relates to the allegations that staff do not ensure that residents in care are provided with food that is of good quality and that staff do not provide activities for residents in care: Based on interviews and observations, 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(a) and 87219(a). An exit interview was held with Clark. Appeal rights and a copy of this report were left with Clark. During this time period, LPA Moleski did not smell any odors of urine or feces from residents or from their bedrooms. LPA Moleski did observe staff assisting residents to the bathroom in order to care for their continence needs, and otherwise observed residents being assisted with their activities of daily living (ADLs). LPA Moleski observed residents’ clothing and bed linens to be clean. LPA Moleski interviewed four residents who were able to respond verbally and coherently (R1, R2, R6, and R7). Of these, two were not diagnosed with any sort of cognitive impairments (R2 and R7). R1 voiced no concerns with their quality of care, and said they receive all assistance when needed. R2 voiced no concerns with quality of care, and said that other residents are cared for appropriately by staff, such as ensuring that they are bathed and that their diapers are changed regularly. R6 voiced no concerns with their quality of care and said they had their basic needs met. R7 said that although they did not receive showers, they do receive bed baths on a regular basis. R7 said they receive assistance with other ADLs when requested. In interviews, four residents’ responsible parties (R1’s RP, R4’s RP, R5’s RP, and R6’s RP) voiced no significant concerns with the quality of direct care at the facility. The department has determined the following as it relates to the allegations that staff do not ensure residents have clean linens, that staff do not assist residents with their ADLs, and that staff do not assist residents with toileting: Based on interviews and observations, 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 Clark.