Complaint·March 25, 2026

Collateral interviews corroborate staff does not ensure to meet residents' dietary needs. Collateral interview was conducted with Person 2 (P2) in which they did not express any concern around meals for R2;P2 stated that R2 does not have a special diet. LPA conducted a collateral interview with Witness 1 (W1), W1 stated, they and their family "had to purchase food out of pocket because the quality the facility provided was so low". One current resident (R4) stated that most meals does not usually include fresh fruit and vegetables and there is usually canned or frozen meals. LPA observed French fries and fish stick was served for lunch. A custom lunch of veggies and fruit was provided to one resident(R4) per their request. On 2/4/26 and LPA observed meals consisted of frozen meals. Dinner on 3/25/26, was Chicken Alfredo and sweet peas (frozen). On 3/13/25, 2/4/26, and 3/25/26, LPA did not observed snacks to be provided in between meals. LPA observed there is a sample menu available in the facility binder, however it is not followed on a daily basis; S1 stated the menu is used as a guide. S1 stated there are two main care staff whom are in charge of preparing meals but they are in charge of menu design. On 2/5/26, S1 stated they were tried out a meal service called "Hungry Root" which provide healthy meals. On 3/25/26, S1 stated he tried Hungry Rot for about three weeks in February but they did not continue the service due to the portions not being enough. S1 stated they are back to doing weekly groceries and will be improving meal options by seeking out additional education and resources. Based on interviews and record review , the allegation "Staff does not ensure to meet residents' dietary needs" 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 conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights was left at the facility. Based on interviews and record review of the LPA and review of records the allegation that "Staff does not ensure resident's bathing needs are being met" is unsubstantiated, as there is not a preponderance of the evidence to prove that the alleged violation occurred. 2) It was alleged that “Staff isolates resident in bedroom for an extended period of time.”, this investigation consisted of interviews with staff, residents, records review, and observations. This investigation focused on Resident 5 (R5). As of February 2025, R5 no longer lives at the facility. LPA interviewed one residents, three collateral witnesses, and 3 staff. 3 out 3 three staff (S1-S3) declined the allegation that staff has isolated any resident in their bedroom for an extended period of time. LPA provided guidance care and supervision, personal rights, and activities. LPA was not able to interview four residents. Person 2 (P2 and Resident 4 (R4) did not express any concerns around the allegation that staff isolates resident in bedroom for an extended period of time. R4 stated they are usually in their room and is obtaining physical therapy services to try to be more active and less isolated. S1 stated residents are encouraged to come out of their room, but they sometimes do not want to and choose to stay in their rooms. Based on interviews the allegation that “Staff isolates resident in bedroom for an extended period of time” is unsubstantiated as there is not a preponderance of the evidence to prove that the alleged violation occurred. 3) It was alleged “Staff does not ensure resident is properly dressed for the day”, this investigation consisted of interviews with staff, residents, records review, and observations. This investigation focused on Resident 5 (R5). As of February 2025, R5 no longer lives at the facility. LPA interviewed one residents, two collateral witnesses, and three staff. 3 out 3 three staff (S1-S3) declined the allegation that staff does not ensure resident is properly dressed for the day. LPA provided guidance care and supervision, personal rights, and activities. LPA was not able to interview four residents out of five current residents. Person 2 (P2) and Resident 4 (R4) did not express any concerns around the allegation staff does not ensure resident is properly dressed for the day. S1 stated residents are assisted with dressing as needed. CONTINUED ON 9099A-C Based on interviews and record review of the LPA and review of records the allegation that "Staff does not ensure resident is properly dressed for the day" is unsubstantiated, as there is not a preponderance of the evidence to prove that the alleged violation occurred. 4) It was alleged “Administrator does not ensure to be on premises for a sufficient number of hours”, this investigation consisted of interviews with staff, residents, records review, and observations. LPA interviewed one resident, 2 collateral witnesses, and 3 staff. 3 out 3 three staff (S1-S3) stated that the Administrator is on premises often and available via phone at all times. LPA was not able to interview four residents out of five current residents. Person 2 (P2) did not express any concerns around the allegation that Administrator does not ensure to be on premises for a sufficient number of hours. LPA conducted a collateral interview with Witness 1 (W1), W1 stated, they only saw the administrator at the facility once ever 7-10 days during the four months they resided in the care home. Per LIC 500 indicated S1 is scheduled Monday- Friday between 8:00AM -12:00PM, S1 stated they are on-call/variable scheduled, "PRN" Monday- Sunday. S1 stated they do have another job as a Dialysis Technician. Resident 4 (R4) stated they see S1 at the facility about 3-4 times per week. LPA provided guidance around Administrator Qualifications and expectations; as "The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section". Per Title 22 regulation 87405. Based on interviews and record review of the LPA and review of records the allegation that “Administrator does not ensure to be on premises for a sufficient number of hours” is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of four allegations listed above are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was provided to Administrator (S1).