complaint·August 22, 2025

Two out of two family members who frequently visit reported that they have observed residents freely accessing the common areas and expressed no concerns. Two out of two representatives from outside agencies confirmed they have witnessed residents in the common areas. During a site visit on 06/18/2025, LPA Lee and Ombudsman Byron Toliver observed a resident in the dining and in the kitchen. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff did not allow residents to access the common areas in the facility. An allegation was made that staff spoke to residents in an inappropriate manner. The investigation included interviews with facility staff, residents, resident responsible parties, and outside agencies, along with direct observations. Four staff members were interviewed. All four denied that any staff had spoken inappropriately to residents under their care. Two residents were interviewed. One of the two residents stated they had not witnessed staff speaking inappropriately to residents and expressed no concerns regarding the behavior of facility staff. Two family members reported that they had not witnessed any inappropriate communication from staff toward residents and shared that their experiences have only been kindness from the facility staff. Two representatives from outside agencies stated that they had not observed any instances of inappropriate communication between staff and residents, and they expressed no concerns. Direct observations were made during a site visit. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver, did not observe any inappropriate communication between staff and residents. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff spoke to residents in an inappropriate manner. It was alleged that staff did not provide residents with adequate food service . This investigation consisted of interviews with staff, residents, and resident responsible party as well at direct observations. Four staff members were interviewed. All four staff denied that staff are not providing adequate food service to residents in care. Two residents were interviewed. One of the two residents stated they have no concern regarding the adequate amount of food being provided and are content with the meals provided. CONTINUED LIC 9099-C Two family members reported that they also had no concerns about the food provided to the residents in care and stated that meals and snacks were "more than generous." Two representatives from outside agencies stated that they have no concerns with the food service being provided to the residents and have witnesses residents being provided with adequate food. Direct observations were made during a site visit. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver toured the kitchen observed that there was an adequate supply of food, including a minimum of seven days’ worth of non-perishable and two days’ worth of perishable food supplies. Moreover, these supplies were accessible to the residents in care. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff did not provide residents with adequate food service. An allegation was made that staff did not ensure the facility was free from pests. The investigation included interviews with facility staff, residents, residents responsible parties, and outside agencies, along with direct observations during two separate site visits. Four staff members were interviewed. All four denied that there was any pest in the facility. Two residents were interviewed. One of the two residents stated they had not witnessed any pest in the facility and expressed no concern. Two family members reported that they had not witnessed any pest in the facility and also have no concern. Two representatives from outside agencies stated that they had not observed any pests in the facility and they expressed no concern. Direct observations were made during two site visits. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver, did not observe evidence of pest in the facility as well as today’s visit, 08/22/2025. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff did not ensure the facility was free from pest. It was alleged that staff did not ensure the facility was properly maintained and that staff did not ensure kitchen utensils were properly maintained. The investigation included interviews with facility staff, residents, resident responsible parties, and outside agencies, along with direct observations during two separate site visits. Four staff members were interviewed. All four staff denied that the facility and kitchen utensils are not properly maintained. Two residents were interviewed. One of the two residents stated they had not witnessed the facility and kitchen utensils not properly maintained and expressed no concern. CONTINUED LIC 9099-C During the visit, LPA Lee and Ombudsman Toliver reviewed residents’ medication on hand and Medication Administration Record (MAR) logs for two residents. The review revealed that resident 1 (R1)’s MAR log was incomplete, with staff initials missing for three separate medications across three different days. Further, a medication audit for R1 showed that the medications listed on the MAR did not match the medications physically present. It was learned that R1 kept part of their medication supply in their personal room, while the rest was stored by the facility in a locked cabinet. This dual storage system contributed to confusion of what R1’s prescribed medications are. A review of R1’s LIC 602 Physician’s Report and LIC 603A Resident Appraisal confirmed that R1 requires assistance with medication management. However, the documents also indicate that R1 is able to manage, administer, and store their own medications, creating confusion around the level of responsibility shared between R1 and the facility as R1 stores some of R1’s medication in R1’s room and the facility store some of R1’s medication in the facility lock cabinet. During the interview process, facility administrator Erica was unable to clearly state which medications were currently prescribed to R1. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was able to corroborate the allegation that staff did not dispense resident’s medication as prescribed. As a result, this allegation is 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 with care staff Edgar Panen and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Two family members reported that they also have no concern with the facility and kitchen utensils not properly maintained and expressed that the facility is very clean, feels very lucky and comfortable that their loved one is house at the facility and feels that the residents is very well taken care of. Two representatives from outside agencies stated that they had not observed any concerns with the facility not being maintained. Direct observations were made during two site visits. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver observed that the facility was clean, free of odors, and in good repair. No signs of mold were found in the residents’ showers, under the kitchen sink, or on the windowsills. No cracks were observed on the floors throughout the facility, and the bathroom walls showed no signs of peeling. The dishwashing sponge was also observed to be clean. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegations that staff did not ensure the facility was properly maintained and that staff did not ensure kitchen utensils were properly maintained. It was alleged that staff did not ensure residents were provided with clean mattresses. The investigation included interviews with facility staff, residents, responsible parties, and outside agencies, along with direct observations during two separate site visits. Four staff members were interviewed. All four denied residents are not provided with clean mattresses. Two residents were interviewed. One of the two residents stated they have no concern that they are not provided with a clean mattress. Two family members reported that they had not witnessed residents with unclean mattresses and had no concern. Two representatives from outside agencies stated that they had not observed any residents with unclean mattresses and they expressed no concern. Direct observations were made during two site visits. On 06/18/ 2025, LPA Lee, accompanied by Ombudsman Byron Toliver inspected mattresses in six resident rooms and did not observe the mattress to be dirty and having any stains as well as today’s visit, 08/22/2025. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff did not ensure residents were provided with clean mattresses. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided to care staff Edgar at the end of the visit.