Complaint·February 19, 2026

During a facility visit on 12/12/25, LPA observed R2’s records including their admission agreement, pre-admission appraisal, and Physicians report (LIC 602) were not available for department review. S1 stated the documents were completed but they were working on records off-site. S1 sent R2’s records to LPA on 2/17/25. Licensee, Lilian Sisyan (S1), stated they went in person to conduct an initial intake interview prior to resident moving in on 11/25/25. It was reported by W1 and W2 that S1 was provided with verification of R2’s needs and level of care prior to acceptance. On 12/12/25, it was learned that R2 moved into the facility on 11/25/25 and they had not been out of bed since move in date, due to the facility not having staff that was able to lift R2 nor a Hoyer Lift that could safely sustain R2’s weight. Since admission, staff confirmed they have been cleaning, bathing, providing meals and all care in bed, as they await a Hoyer lift for R2. R1’s pre-placement appraisal was completed on 11/11/25. S1 went out in person to meet with S1 one time prior to admission on 11/25/25. On 12/17/25, LPA reviewed a copy of a LIC 625 Appraisal dated 11/25/25. Although the appraisal states the residents’ known conditions. S1 states they were unaware of the extent of R2’s needs and behaviors until they moved in and R2's weight is not accurate on the intake paperwork. R2's actual weight has not been confirmed since move in however S1 observed it took four paramedics to transfer them. Moreover, R2’s wheelchair is not a standard sized wheel chair, as it is an extra large wheelchair. It was confirmed by S2 that the wheelchair does not fit through the interior door passageways, making it so R2 is not able to be transported for meal times in the common areas. Intake documents state R2 requests to be transferred onto their wheelchair for meal times, up to three times per day. S1 stated concerns around transferring R2 three times per day due to the level of pain they are under. LPA provided guidance on intake and admission regulations. Based on interviews and record review of the LPA and review of records the allegation, staff did not conduct a proper pre-admissions appraisal for resident is substantiated. Allegation: Staff does not ensure resident is provided adequate care services. It was alleged staff does not ensure resident is provided adequate care services, the investigation into the above allegation consisted of interviews and record reviews. Interviews with S1-S3, it was reported that at minimum residents are checked on about every two hours , or more often if needed. CONTINUED ON 9099-C3 S1 stated there there are at least two staff scheduled to care for up to six residents each shift and one wake staff at night time. On 12/12/25, 87468.1(a) Personal Rights of Residents in All Facilities was cited due to LPA’s observation of mobility devices not being accessible within reach for R2 and Resident 3 (R3) whom are non- ambulatory and require a mobility devices. The Plan of Correction (POC) was cleared by 12/16/25. Moreover, interviews with S1 confirms there was not a Hoyer lift in the facility that can sustain R1’s weight. S1 stated they have had a Hoyer lift that sustains 250 pounds but after observing it takes three paramedics to transfer R2, and a Hoyer lift with a higher weight capacity is needed to safely assist R2. On 2/19/25, S2 stated a Hoyer lift was obtianed December 2025 from another facility due to Master Care not assisting with obtaining the Hoyer lift. Staff did not ensure R2’s wheel chair fits thru the doorways prior to admission. Staff interviews and observations reveal that the wheelchair for R2 is too wide to fit thru all doors because it was an extra large wheelchair. On 12/12/25 and 2/19/26, LPA observed R2's wheelcahir is stored in the backyard. Based on interviews and record review of the LPA the allegation staff does not ensure resident is provided adequate care services is substantiated. Allegation: Staff is retaining a resident who requires a higher level of care. It was alleged “Staff is retaining a resident who requires a higher level of care”, the investigation into the above allegation consisted of interviews and record reviews. Interviews with S1-S3, it was reported that at minimum residents are checked on about every two hours , or more often if needed. Staff said they there are about 2-3 staff scheduled to care for 6 residents each shift. Staff interviews with S2 and S1 and observations corroborate staff did not ensure R2’s wheelchair fits thru the doorways prior to admission, this poses a safety and personal rights risk. Incident report dated 1/6/26, states R2 was sent out to the hospital due to a high level of pain. Per S2, R2 has been in the hospital from 1/6/26 to this day due to the type and dosage of pain medications that R2 is requesting. Per S2, R2 requested new placement and Sutter General Hospital are in the process of obtaining a new placement for R2. Based on interviews and record review of the LPA, the allegation staff is retaining a resident who requires a higher level of care, is substantiated. As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.