Complaint·September 17, 2025

Interviews and record review confirm R1 did not have a POLST, only an advanced directive. It was alleged Staff cannot communicate due to language barrier. Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated. LPA interviewed S2 and S3, whom where working on 8/13/25. Staff were not able to communicate fluently in English. When asked about resident history and care needs, staff where unable to provided complete and accurate responses. Witness interviews corroborate S3 and S2 were not able to give medical history, report on R1's condition, or baseline of R1 to emergency personnel. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation that Licensee did not ensure that resident's records were readily available as necessary is substantiated. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation that staff cannot communicate due to language barrier is substantiated. Two deficiencies were cited per California Code of Regulations, TITLE 22, which can be found on LIC 9099-D. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.