complaint·February 20, 2026

9099C-1.. Allegation: Medication is being mishandled by staff. The allegation states than a Med Tech on the "am" shift has been observed to walk away from the medication cart, without securing it and to leave medications for residents in their rooms without ensuring they are immediately taken. Additionally, loose medications have been found in resident wheelchairs, in beds and on the floor. One Med-Tech explained that the procedure for administering resident medication is to "check the resident's chart, look at the board in the Med Room and check the MAR (Medication Administration Record) if there are any antibiotics to be administered. This Med-Tech explained she looks at each resident's names before administering the meds and confirmed residents "will refuse sometimes and we will try 3-4 times", confirming the meds stay in the cup and she will put the cup back in the medication cart if the resident refuses. The Med-Tech confirmed that staff are not trained to leave medications with residents, asserting, "No, we can't leave medications with residents". A second Med-Tech (pm) stated she "makes sure meds are taken by the resident, residents usually takes meds willingly", and pre-poured meds are in "cups that are in a little case that is locked". A caregiver was asked if Med-Techs will leave the medication cup with pills in the resident's room and go to the next resident's room and replied, "Yes, they leave the whole cart and laptop open"- you can see resident's profile and medications they take. The staff added, "sometimes the Med-Tech will ask a non-Med-Tech, or a caregiver to walk the medications to a resident's room, and this usually occurs on the "am" shift. Another caregiver stated she found a paper cup with a red pill in it in Hallway A and gave it to the DON on October 16, 2025. LPA and their manager spoke to (2) residents in the Assisted Living Unit on January 30, 2026. The residents were asked if Med-Techs leave the medications and then proceed to the next resident's room, or if the Med-Tech waits for them to take the medications. One resident responded "sometimes they leave the medications and go". A second resident stated " they leave the medications- they leave them for me at 8:00 am" and then "around 8:30/9:00 am, I take the medications myself". LPA reviewed the Physician's Orders for these two residents. One resident takes the following scheduled medications at 8:00 am: Buspirone 10mg, Metformin 500 mg, Fluticasone Prop 50 mcg nasal spray The second resident takes the following scheduled medications at 8:00 am: Aripiprazaole 5 mg, Oxybutynin Chloride 5 mg and Phenazopyridine HCL 40 mcg. *cont on 9099C-2.. 9099C-2..LPA reviewed a Nurse Audit for Assisted Living and Memory Care that were completed in July 2025 to evaluate areas of medication storage and systems. Scores for Memory Care ranged from 96%-100% accuracy in (6) of (7) areas, while controlled medications received an 83% accuracy score. For Assisted Living, the same areas were evaluated and given scores from 84% to 94%, with pharmacy processes scoring 100%, and diabetic supplies scoring 67%. Medication carts (2) were reviewed and recommendations were made to ensure all OTC medication has the resident's name on it as room assignments can change, and all House Supply OTC, which will be PRN medications only effective January 2026, be marked as House Supply and are properly logged with start dates. Another observation made during the audit was that staff were occasionally pre-signing before the change of shift occurred, when staff should only be signing once the count has been completed, including when working a double shift. Based on information obtained, the portion of the allegation about staff leaving medications for residents in their rooms without ensuring they are immediately taken is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff is not communicating with other staff at shift change . T he allegation states that on/around September 2025 and October 2025, the facility did not have cross over meetings for caregiver staff to attend at shift change to receive resident status updates, and staff communication was very poor. One caregiver staff stated in October, 2025, that there is "no communication at cross over meetings", and she doesn't know which residents are on hospice or home health, or if there have been any concerns/changes the prior shift has to report. A second staff stated in January 2026, " Yes, generally we have cross over meetings" and explained "we didn't have shift meetings at that time", referring to on/around October 2025. A third staff stated in January 2026, "At that time, (October (2025), we did not have them", explaining that staff leaving their shift would just spend (5) minutes talking to the staff arriving, and commented, "the facility needs more structure", and commented, "Just now, starting last month, we are having meetings at shift change". A Med-Tech in January 2026 indicated caregivers will meet outside the common area to discuss if there are any changes in the residents. *cont on 9099C-3.. 9099C-3.. The HR Director was asked about shift change meetings in January 2026 and explained, "Caregivers on the "am" shift fill out a form and communicate- the caregivers give it to a Med-Tech "pm" staff- they talk in the hallways or look at the form", and stated there are stand-up meetings at 9:30 am on days we have events or the day before. The DON stated in February 2026 that a cross-over form was created prior to October 2025, but not all staff were not using it in October, but now they are. The DON stated that Med-Techs have always met with their caregivers at the start of the shift. Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Licensee retaliated against staff for speaking with state staff at the facility. The allegation states on October 14, 2025, an LPA came into the facility and staff (S1) was told to go and talk to her. (S1) states they told the interviewer everything she had observed and what was going on. When LPA asked to speak to additional staff, only one of three staff went to speak to the LPA. The next day, October 15, 2025, (S1’s) supervisor told them they wanted to speak to them about their conversation with the State yesterday and on October 16, 2025, they were called into a manager’s office and given a termination letter. LPA reviewed the “ Notice of Termination” letter issued on October 16, 2025, that states (S1’s) employment is being terminated effective immediately, October 15, 2025. The letter references (2) specific dates and (3) incidents, as a basis to issue the termination letter. The first incident notes on October 9, 2025, (S1) was observed to show unprofessional behavior with a hospice nurse after being asked to leave the resident’s room, and (S1) became defiant with a Med-Tech. LPA was provided with (2) different hospice staff names and contacted each one. Both hospice staff confirmed that they did not recall this incident and stated they would never ask a caregiver to leave a resident’s room, as they often need their help. Interviews with several managers revealed that no manager had contacted the hospice staff to confirm the incident occurred but received this information from a staff that overheard the incident. *cont on 9099C-4.. 9099A-C-1.. Allegation: Vanity lights in resident rooms need to be replaced. The allegation states that work orders were submitted for vanity lights in resident rooms but are not not fixed timely. Room numbers were not provided. LPA and the Director of Nursing toured (5) resident rooms in the "A" Hall in Assisted Living Unit (ALU) on October 30, 2025. In one room, the DON had to push the reset button on the right side (A4) to get the vanity light to go on. In the (4) other nearby rooms, the vanity lights worked fine and there were no issues. The DON commented that both vanity lights were replaced a couple of days ago in one of the rooms (A9). LPA reviewed a copy of the Maintenance Request Worksheet- for jobs logged starting from September 30, 2025 through October 29, 2025. The maintenance log shows the following repairs were made related to bathroom lights in the ALU: 10/15/25- A4-B- Bathroom sink light out and on 10/29/25- ALU- room #D8- sink light out . T he Maintenance Director was interviewed about the facility's Work Order processes and documentation. The Director indicated there is a work order binder at the front desk where maintenance requests are kept and confirmed that if the entry on the worksheet is "checked off, then it's been completed, which is usually within the next day". All of the jobs entered on the log were checked off except for (2) entered on October 28 and 29, 2025, which were for sink lights needing replacement in the facility's Memory Care Unit. Also discussed was how there is not a completion date/column listed currently on the form and how it would be a "best practice" to have a column to confirm when the job was completed. The Director agreed to add a column to the worksheet. Based on information obtained, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. 9099C-4.. LPA interviewed the Med-Tech referenced in the letter who confirmed (S1) was asked to assist a resident who needed assistance with having their top changed after breakfast, and (S1) stated she would do so once she finished another task. The Med-Tech stated this discussion happened between 7:30 am-9:00 am and indicated she could not recall an incident involving (S1) and a hospice nurse on that day. The second incident states on October 15, 2025, multiple staff members observed (S1) to show inappropriate behaviors with resident (R1) in the hallway while trying to assist (R1) into a wheelchair. LPA was provided with multiple written statements from staff who observed the specific incident. LPA interviewed each staff and confirmed that each written statement corroborated with what each staff stated they had observed and with what other staff had observed. (S1) expressed she was never asked to leave a resident’s room by a hospice nurse, including on October 9, 2025, and explained on October 16, 2025, she was trying to get (R1) to sit in their wheelchair due to recovering from a recent fall, and was never physically forceful with (R1), or any other resident. LPA was provided with a copy of a text message sent from a manager to (S1) on October 15, 2025 (7:13 am) that states, “We would like to have a conversation of what you reported to state yesterday”. (S1) responded back “Ok”. Since the manager could not be at the facility on October 15, 2025, (S1) did not meet with any managers until the morning of October 16, 2025, when the termination letter was issued. The Termination letter closes by saying “ Because you are still within your 90- day introductory period, and due to the severity and repeated nature of these incidents , management has decided to proceed with immediate termination of employment”. The HR Manager stated that (S1) had received at least (2) write-ups and confirmed she was not able to initially, or later, locate the write-ups prior to termination, or any other documentation showing a manager had discussed concerns with (S1) about their job performance. ( S1) stated she was told by a manager in the meeting on October 16, 2025, that there had been multiple complaints about her, but was never approached by managers to discuss any issues, and only signed paperwork when hired on August 27, 2025, and terminated on October 16, 2025. (S1) indicated that during the termination meeting, managers could not provide her with any documentation regarding complaints made against her, including for the incidents referenced in the Termination Letter on October 9, 2025, and October 15, 2025, or any documentation that a manager had discussed job performance concerns with her. *cont on 9099C-5.. 9099C-5.. Although the Termination Letter does not reference (S1) speaking with the state on October 14, 2025, (S1) stated that during the termination meeting, she was told by a manager to only provide limited information to state personnel, when asked. LPA interviewed several other staff who indicated they were also told by management, around October 15, 2025, to tell State employees that everything is fine with the residents, and there are no problems. Based on information obtained during the investigation, the allegation is found to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) citations are issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.