Complaint·January 21, 2026

Allegation - Staff did not ensure residents received sufficient beverages, resulting in dehydration. The investigation into this allegation consisted of interviews, record reviews and observations. Through interview, witness (W1) believes the facility did not give resident (R1) enough to drink at meals and medication times. W1 said staff once saw R1 “guzzling” ice water and took that as a sign of dehydration. Interviews with staff revealed that water is offered at each meal, often during activities and whenever residents ask. Staff stated that they do not track or log daily fluid intake unless residents show a change in condition and placed on alert; R1 was not on dehydration alert. Dietary and care staff described hydration stations in common areas, water pitchers on dining tables, drinks in the dining-room fridge/freezer, and a mobile cart that offers water, juice, popsicles, and fruit, especially on hot days. Through interviews with current residents in care, they did not report any problems with food or hydration issues. One resident stated that there are places in the facility to get water. Records review showed R1 was not on dehydration alert. Review of facility’s newsletter for July 2025 that provides residents with information and reminders to hydrate, especially during summertime, and the importance of avoiding dehydration, UTI’s, heat stroke and other heat related conditions. During this LPA’s observations on 7/1/25 and 12/26/25, LPA observed hydration stations with water, coffee, and tea near the lobby. At lunchtime, LPA observed a glass of water at each dining table place setting, and many residents also had juice, coffee, or tea. Menu items were posted and easy to see. Staff did not report signs of dehydration for R1 before the hospital transfer, and R1 was not put on a dehydration alert. While W1’s concerns are noted, there is not enough evidence to show that staff did not provide sufficient beverages to R1. Based on the information gathered, the allegation that staff did not ensure the resident received sufficient beverages, resulting in dehydration, is unsubstantiated . {2 of 5} Allegation - Licensee did not adhere to resident's admission agreement: The investigation into this allegation focuses mainly around R1’s situation. The investigation included interviews with staff, review of the admission agreement signed on January 22, 2025, R1’s payer ledger, and related correspondence. Based on interviews, R1 was not denied return to the community following hospitalization. The administrator explained that R1 was sent to the emergency room on March 18, 2025, due to stroke symptoms. After hospitalization, the facility’s Director of Health and Wellness typically assesses residents before readmission to ensure care plans remain accurate and regulatory requirements are met. In R1’s case, there was a change in care needs under review. During this time, R1’s Power of Attorney (POA), decided to seek alternative placement that could accommodate these changes and was more financially feasible. Through interviews and record reviews, the POA provided a written 30-day notice via text message on April 2, 2025, which was confirmed by a screenshot and a written message dated April 30, 2025. Review of the admission agreement shows that residents may terminate the agreement at any time by giving a 30-day written notice, and they are responsible for paying all rent and fees during that notice period, even if they do not occupy the apartment. Review of R1’s payer ledger confirms that R1 was billed through April 30, 2025, consistent with the agreement terms. Staff interviews also confirmed that level-of-care charges stop when a resident physically leaves the facility, but rent obligations continue through the notice period, per admission agreement. R1’s last billing stopped on April 30, 2025. Based on the evidence, the allegation that the licensee did not adhere to R1’s admission agreement is unsubstantiated . The facility followed the signed agreement by requiring payment through the 30-day notice period and did not deny R1’s return. {3 of 5} Allegation - Staff did not follow resident's diet order: Investigation included interviews with staff, residents in care, and other individuals involved with the care of R1, review of R1’s care plan, diet order, admission agreement, and facility observations. Interview with witness (W1) stated that R1 was diabetic and was supposed to receive a carb-controlled diet after switching from insulin to oral medication. W1 stated that R1 ate the same meals as other residents and that this caused R1’s blood sugar to rise. W1 also reported that blood sugar checks were not done regularly. During interviews, staff explained that diet orders are reviewed during admission and any changes are communicated to the kitchen. Staff also stated that menus are planned by a dietitian and that special diets are documented in a binder accessible to kitchen staff. Interviews with current residents in care did not report issues with food services and did not report staff not following their diet, food allergies or food preferences. Through record reviews, R1 had a diabetic diet. Review of the diet order form signed by the health practitioner on January 16, 2025, indicated R1 was to have a consistent carbohydrate diet, meaning a consistent amount of carbohydrates at meals and snacks. Foods with high sugar were allowed when planned into the total carbohydrate allowance for the meal. Additionally, review of training records showed staff were trained on diet and texture modifications. During observations, LPA observed menus posted and water provided at tables, and interview with kitchen staff confirmed that alternative meals are available upon request. Based on the information gathered, there is not enough evidence to prove that staff did not follow R1’s diet order. Therefore, the allegation is unsubstantiated . {4 of 5} Allegation – Unlawful eviction: The investigation into this allegation focuses mainly around R1’s situation. The investigation included interviews, review of R1’s admission agreement, termination clause, and facility records. According to the complaint, R1 was hospitalized on March 18, 2025, and was later informed that the facility would not allow R1 to return. The facility did not provide an eviction notice and that POA learned of the eviction indirectly through hospital staff. Review of R1’s admission agreement and termination clause shows that the facility may terminate the agreement with a 30-day written notice for reasons such as nonpayment, failure to comply with laws or facility policies, or if the resident’s needs can no longer be met. The agreement also states that a 3-day notice may be given with prior approval from the Department of Social Services if the resident poses a health or safety risk. CCR Title 22, Section 87224, requires proper written notice and DSS approval for certain evictions. Records show that R1’s POA submitted a written 30-day notice, via text, on April 2, 2025, to move R1 out of the facility. Staff interviews confirmed that the facility did not issue an eviction notice and did not deny R1’s return; instead, the POA chose an alternative placement that could meet R1’s changing care needs. Based on the information reviewed, there is insufficient evidence that the facility unlawfully evicted R1. The move-out was initiated by the POA, and the facility followed the admission agreement signed by R1 and/or R1’s POA. Therefore, the allegation is unsubstantiated . An unsubstantiated finding means that although the allegation may have happened or valid, the preponderance of evidence standard is not met. No deficiencies were cited as a result of this visit. An exit interview was conducted with S1 and AD, and a copy of this report and appeal rights were provided. {5 of 5}