Complaint·July 14, 2025

LPA Moleski interviewed six other residents (R2-R6). R2 said that once, a staff member yelled at them. However, R2 said that they did not remember who the staff member was, or what exactly had happened. R3-R7 reported no concerns regarding staff conduct. S2-S5 reported no concerns regarding staff conduct. S1 also said they had seen on daily care task sheets handwritten notes indicating that R1 could not have alcohol or sweets. LPA Moleski interviewed R1 in their room on 2/4/25, and observed alcohol and sweets present and accessible to R1. In an interview, R1 said that staff do not restrict their diet. LPA Moleski reviewed daily care task sheets for the months of December and January and observed no notes indicating R1’s diet was to be restricted. LPA Moleski reviewed R1’s individual service plan, dated 8/27/24, which indicated R1 had no dietary restrictions. LPA Moleski reviewed R1’s LIC 602, which indicated that R1 consumes alcohol, and did not require any special dietary restrictions. In interviews, multiple staff members said that, several months prior to this complaint being filed, R1 was drinking to excess, and suffered at least one fall around the same time. S2 said that staff were encouraging R1 to drink less, to avoid falling while inebriated. S4 said that staff were encouraging R1 to drink less to avoid negative complications with painkillers he was taking at the time. Both S2 and S4 said that R1 was allowed to drink as much as they wanted if they wanted more. The department has determined the following as it relates to the allegations that staff yell at residents, that staff threaten residents, and that staff are restricting food/drink from a resident: Based on interviews, record review, and observation, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Weininger. This report was amended to correct an error in the use of confidential code identifiers. LPA Moleski interviewed the two staff members who were working with R1 during the previous PM shift (S2-S3). S2 said that they do not usually work with R1, so they did not know R1’s routine. S2 said that R1’s pajama pants weren’t available, as they were either in the washer or dryer. S2 said they told R1 they would get the pajama pants once they were clean, then took R1’s hearing aids out. LPA Moleski asked if R1 understood the situation and was fine with going to sleep without pajama pants. S2 said that they had already taken R1’s hearing aids out, so R1 wasn’t listening and kept talking over S2. S3 said that they also rarely work with R1, and did not know at the time if R1 was going to urinate in bed. S3 said R1 was put to bed without pajama pants for that reason. S3 said R1’s pajama pants were in the dryer at the time. S3 said they tried to explain the situation, but R1 did not understand. R1’s LIC 602, dated 2/22/24, indicated that R1 has a hearing impairment and uses hearing aids. R1’s individual service plan, dated 8/27/24, indicated that R1 "requires hands on assistance with dressing and undressing" and that "assistance with clothes selection" was included as part of this service. The plan stated that care staff were responsible for providing “hands on assistance choosing clothing, dressing and undressing" with an expected goal of maintaining "privacy, safety and comfort." The plan also indicated that R1 was hearing impaired and that R1 "needs assistance with hearing aid care," such as "donning and doffing hearing aids." R1’s preplacement appraisal, signed by Weininger on 1/25/23, states that R1 wears hearing aids, but even so is still “very hard of hearing,” and that R1 “needs help dressing.” Title 22 of the California Code of Regulations (22 CCR) Section 87307 states that “equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available for each resident” and that the licensee shall assure provision of “basic laundry service.” Additionally, 22 CCR Section 87465(a)(3) states that “when residents require … hearing aids … the staff shall be familiar with the use of these devices, and shall assist such persons with their utilization as needed.” 22 CCR Section 87468.1(a)(12) grants residents the right “to wear their own clothes” and to “keep and use their own personal possessions.” [continued on 9099-C] The department has determined the following as it relates to the allegation that staff did not assist a resident. Based on interviews and record review, 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 87464(f)(4). An exit interview was held with Weininger. Appeal rights and a copy of this report were left with Weininger.