Complaint·August 6, 2025

open. LPA closed the door and provided technical assistance to staff regarding the need to keep doors without screens closed to ensure the facility was kept free from insects and pests. When this LPA entered the memory care community, she checked the rear exit and it was not alarmed and the door opened freely to the back parking lot. This deficiency will be cited during a follow-up case management visit. LPA also observed residents' artwork (painted canvases) posted on the walls in the hallways of the community. There were 11 residents in the dining room enjoying a morning snack and 4 residents relaxing on furniture in the adjacent hallway supervised by staff. Upon returning to the assisted living area of the community, LPA observed an unlocked laundry room with detergent present and accessible to residents in care. This deficiency will be cited during the future case management. LPA also observed 10 residents playing Bingo led by the activities assistant. 4 other residents were on an outing to botanical gardens supervised by 2 staff. When LPA returned to the lobby area of the facility, LPA noted that the door to the Medication Room was open and that the keys were in the medication cart and the cart was unlocked. There were no medication technicians in the room at this time. LPA interviewed 3 staff members (S1, S2, and S3) who stated that they were instructed to leave the door open so that residents would be able to find them more readily when they were in the med room and not in the community. LPA reminded them that there was no one present in the room at the time the LPA walked in; the door should have been closed and locked so that all medications were inaccessible to residents in care. This deficiency will be cited in the follow-up case management visit. Regarding the allegation: Room used for behavioral interventions is malodorous. Legacy Oaks launched a program where they utilized staff trained on behavioral intervention techniques to assist and redirect residents having behavioral expressions. Residents from both the assisted living and the memory care communities were brought to room 37 where they could get away from triggers, play a game, watch a movie, and behaviors could be de-escalated. LPA visited room 37 which was designed to be a resident room, and observed the following: The window was open and a fan was seated on the floor on one side of the room and blowing the decorations on the wall opposite. There was a diffuser on the counter. LPA observed shelves with games and activities along with a table in the center of the room surrounded by folding chairs. There was a sofa and other furnishings and decorations. LPA observed that the brown carpet was stained in several places, the largest being in front of the sofa area and another extending toward the kitchenette. LPA also observed that the baseboard molding adjacent to the carpet was warped and falling down in places. By the sink, it was completely detached and on the floor. LPA took pictures for documentation purposes. LPA then observed a small bookcase slightly in front of the bathroom door. LPA and a staff person moved the bookcase and this LPA entered the bathroom. LPA observed a broken toilet. The tank had been removed and was in the bathtub. The toilet had dirty brown standing water and toilet paper in it. The vanity was missing the door to the cabinet under the sink and Clorox and other toxic cleaning supplies were observed underneath. The tub/shower unit also had a metal shelving unit in it along with 2 buckets. One of the buckets approximately (3-5 gallons) had standing water in it. LPA took pictures for documentation purposes. A staff member, S1 walked in while this LPA was recording observations. LPA interviewed S1 and asked about the condition of the room. S1 stated they were told the room smelled badly because of the carpet and that was why they were constantly cleaning and brought in the air diffuser. LPA observed that her own eyes were irritated upon entering the room. When Designee Ashley Sylve arrived, LPA requested that the diffuser and fan be shut off and the window closed to see if she could assess what the room smelled like without them. LPA returned later with Sylve and found the room to be malodorous. LPA also observed that maintenance had begun removing all the furniture. Sylve stated that the room was being emptied out in preparation for maintenance to conduct all necessary repairs. While the room was used for behavioral interventions, it was not being used for the purpose that was stated in the facility's plan of operation and facility sketch. This violation will be cited in the follow-up case management visit along with the others motioned previously. Sylve stated they would conduct their Residential Habitation (RH) program in the activities rooms going forward. Room 37 room would be prepared for resident occupancy in order to return to compliance. The allegation: Room used for behavioral interventions is malodorous. Based on observations and interviews with S2, S3, and S4, room 37 was found to be malodorous and unsanitary when this LPA observed the stained carpet, baseboard molding in disrepair, and the dirty brown standing water and toilet paper in the broken toilet in the bathroom. Prior to closing this report, this LPA also observed that the Business Office door was open with no staff present, and resident files with confidential financial information were left accessible to anyone walking by. One of the filing cabinet drawers was left open and in plain site. According to the California Code of Regulations, Title 22, due to time constraints, the other deficiencies noted in this report will be cited in a follow-up case management visit. A copy of this report was provided along with APPEAL RIGHTS and and exit interview was conducted.