complaint·October 27, 2025

In an interview, R6 said staff assist them with dressing, showering, and with transferring. R6 said they cannot stand on their own, but said that staff do try to help them using the Hoyer lift. When asked, R6 said that they had not received a shower within the past week, but said that staff do provide bed baths in order to meet their hygiene needs. R6 was not able to recall when they had last received a bed bath. R6 appeared clean, and did not present any odors indicating their hygiene needs were not being met. In interviews, caregivers C1 and C2 said that R6 does not always want to get up out of bed, and when R6 does get out of bed, they often want to return to bed shortly afterward. C1 said that R6 receives daily bed baths. C2 initially said that R6 receives bed baths every other day, but later said that R6 receives bed baths daily. LPA Moleski interviewed R6's responsible party (R6's RP) over the phone during this visit. R6's RP was aware that R6 receives bed baths, and expressed no concern with this accommodation. R6's RP said that R6 has numerous medical conditions which make it difficult to move around. R6's RP said they have witnessed staff transferring R6 previously. In an interview, R6's roommate, R2, did not voice concerns regarding R6's care. R2, who moved into this facility in September, said they did observe odorous residents around the time R2 moved in, but R2 said this was the choice of those residents. Per 22 CCR Section 87468.1(a)(16), residents retain the right to refuse any service, including hygiene care. R2 said that they have not observed any issues since then. R2 said they regularly observe staff transferring other residents up out of bed. The department has determined the following as it relates to the allegations that staff do not assist a resident with showering and that staff do not assist a resident with ambulating: Based on interviews and observation, 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 these allegations. An exit interview was held with Clark. A copy of this report was left with staff member Leashia Tyrell-Moore. During a visit on 10/16/25, LPA Sommer Hayes observed a child visitor accompanied by Clark. LPA Hayes observed the child roaming around the facility and touching fruit sitting on the kitchen counter. On that same date, LPA Hayes observed raw shredded cabbage without dressing served as a side salad. In an interview conducted by LPA Hayes, R2 reported that hot dog buns had been used for sandwiches, as staff had run out of sliced bread. 22 CCR Section 87555(b)(23) requires that " all readily perishable foods or beverages ... shall be stored in covered containers... " 22 CCR Section 87555(b)(28) requires that " all food shall be protected against contamination. " The department has determined the following as it relates to the allegation that staff do not serve residents food of good quality: Based on interviews and observations, 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 87555(a). This facility was previously cited per 22 CCR Section 87555(a) in response to a substantiated complaint on 06/03/2025. As this is a repeat violation, a civil penalty in the amount of $250 is hereby assessed. An exit interview was held with Clark. Appeal rights and a copy of this report were left with staff member Leashia Tyrell-Moore.