complaint·September 9, 2025

LPA Moleski performed this count in front of a staff member (S1) to ensure accuracy. S1 raised no concerns regarding the accuracy of the count. LPA Moleski performed a similar count for one of R1's painkillers, and observed another discrepancy. LPA Moleski observed a start date of 6/8/25. R1 was ordered to take one tablet daily. R1's centrally stored medication records indicated the medication was started on 6/8/25. LPA Moleski observed 81 doses administered between that date and the date of the audit, which should leave 19 tablets remaining in the bottle. LPA Moleski counted out 20 tablets in the bottle. S1 observed this count as well and similarly did not voice concerns over the methods used or the accuracy of the count. An antidepressant prescribed for R1 did not have a start date recorded, making an audit impossible. LPA Moleski received an incident report from Bigelow on 8/25/25. According to the incident report, a resident (R2) refused personal care, and "the strong odor associated with the resident's refusal of hygiene care became noticeable in the common areas and was causing discomfort for other resident." The incident report stated that staff continued to "make efforts to support" R2, but no description was provided of efforts to eliminate or reduce the odor. During LPA Moleski's visit on 8/28/25 and on LPA Moleski's visit on 9/9/25, fairly mild incontinence odors were observed to be present in R2's room. In an interview, R1's placement agent said they had smelled strong incontinence odors on multiple occasions. In interviews, R1 and R3 said that they had sometimes smelled odors coming from R2. LPAs Moleski and Lindstrom spent several hours at this facility during today's visit. LPAs Moleski and Lindstrom observed no activities being offered to residents. LPA Moleski observed no activities being offered during his visit on 8/28/25 either. In interviews, R1's placement agent, as well as R1-R5, said that there are no activities offered to residents. R3 and R5 said there are games at the facility, but they are not used. The department has determined the following as it relates to the allegations that staff did not administer medication as prescribed to a resident in care, that staff did not prevent the facility from being malodorous, and that staff are not providing activities for the residents in care: Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87465(a)(4), 87625(b)(3), and 87219(a) . An exit interview was held with Bigelow. Bigelow said staff member Aisake Jemesa could sign this report in her absence. Appeal rights and a copy of this report were left with Jemesa.