Complaint·December 4, 2025

During interviews with two staff (S2 and S5) and two residents (R1 and R2) it was learned that Resident 1 (R1), whom is a dependent adult, reported to S2, P1, S6 and P2, that they had been inappropriately touched by Staff 3 (S3) on 9/23/25. Record review and interviews confirm that S1- S7, P1, and P2 did not complete report the incident timely to community care licensing regional office via unusual/special report, phone call, nor an SOC 341 form. S1-S7 are mandated reporters, however they did not ensure timely reporting requirements were completed when the R1 reported they were inappropriately touched in a sexual manner to staff. Based on interviews and observations of the LPA and review of records the allegation that staff failed to report suspected sexual abuse of a resident, is substantiated. A civil penalty for repeat violation applies. Allegation: Staff did not ensure that residents’ dietary needs are met It was alleged that staff did not ensure that residents’ dietary needs are met, this investigation consisted of facility observation, interview with residents in care, and resident records review. On 9/29/2025, LPA Tamayo conducted a visit to the facility and observed 5 residents sitting at the dining room table having lunch and dinner in which they were consuming food items that did not meet their prescribed dietary requirements; it was observed that staff preparing lunch was frozen corn dogs and pizza.R6 has a diagnosis of diabetes and there is no special menu nor alternatives offered for them. Interview with 2 out 5 residents revealed concerns with food being served. 5 out of 5 residents in the facility stated in between meal snacks are not being provided. LPA did not observe snacks were made available to residents in between meals during multiple visits including 4/25/25,6/13/25,6/30/25,7/23/25,8/12/25, and 9/29/25. Additional review of facility’s Admissions Agreement indicates that residents in care will receive nutritious and well-balanced meals that meet their individual dietary meals requirements. This was observed not in compliance with Title 22 regulation 87555(a). LPAs did not observe any fresh fruit out on the counter available to residents. LPAs observed waffles, oranges, and grapes were given for breakfast and lunch was burgers, chocolate cake, orange, and soda. S2 stated canned soup is available for anyone who wants an alternative. Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure that resident's dietary needs are met, 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 S1-S3 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Allegation: staff sexually abused a resident, the investigation It was alleged that staff sexually abused a resident, the investigation into the above allegation consisted of interviews and record reviews. On 09/29/2025 and 10/07/2025, Resident 1 (R1) was interviewed by the department, R1 reported that they had been inappropriately touched by Staff 3 (S3) on 09/22/2025, after S3instructed by R1 to apply Witch Hazel around her groin area and upper inner thighs. R1 denied penetration and that S3 touched their clitoris. R1 recalled S3 saying, “It’s good for me to massage you” and “Let me know when it feels good,” while applying the Witch Hazel. R1 reported other caregivers do not massage them while applying the Witch Hazel. R1 asked S3 to stop touching her and they did. Based on the interview, the information has no basis to support an allegation of sexual abuse. Four staff (S2,S4, and S5) were interviewed and two residents (R1-R2) of which none reported to have witnessed any staff sexually abuse a resident. Based on interviews and observations of the LPA and review of records, there is not a preponderance of the evidence to prove staff sexually abused a resident. Allegation: Staff did not ensure that facility is maintained clean It was alleged that staff did not ensure that facility is maintained clean, the investigation into the above allegation consisted of interviews and record reviews . Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure that facility is maintained clean It was, is unsubstantiated. Allegation: staff did not ensure that residents’ incontinence needs are met It was alleged that staff did not ensure that residents’ incontinence needs are met, the investigation into the above allegation consisted of interviews and record reviews. R1 reported there was two occurrences when incontinence care was not met. A review of R1’s 602 physician’s report states that R1 needs assistance with toileting, bathing and grooming . Based on interviews and observations of the LPA and review of records, there is not a preponderance of the evidence to prove staff did not ensure that resident's incontinence needs are met. CONTINUED ON 9099A-C Allegation: Air conditioner is not in good working order, It was alleged that the air conditioner is not in good working order, the investigation into the above allegation consisted of interviews and record reviews. On 9/29/25, R1-R5 stated the air conditioner is in working order. S2 stated they contacted a maintenance worker the week of 9/15/25 when they noticed the Air conditioner was not operating properly and it was fixed immediately. Based on interviews and observations of the LPA and review of records the allegation the Air conditioner is not in good working order is unsubstantiated. Although the allegations 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 the above allegations are unsubstantiated, but if any additional information is received this complaint can be amended and the findings 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 left at the facility.