complaint·January 13, 2026

Allegation: Staff were not checking resident’s blood pressure resulting in hospitalization According to resident (R1’s) personal service plan, facility staff are to “consider possibility of orthostatic hypotension and respond as needed”. R1’s progress notes indicated that, on October 5, 2025 at 12:19pm, R1 was not feeling well, had no fever, but said that their stomach aches. R1’s progress notes indicated that, on October 6, 2025 at 9:44am, R1 indicated that their stomach was cramping. Progress notes indicated that facility staff would contact R1’s responsible party to have them take R1 to the doctor. The facility does not have any progress notes between September 18, 2025 and October 5, 2025 indicating any observations of R1. R1’s responsible party indicated that when they arrived at the care home R1 did not look well and they were told by staff that R1 had not been eating and had been staying in bed for the past 3 days. R1’s responsible party indicated that, on October 6, 2025, they took R1 to a routine doctor’s visit where they were informed that R1 had low blood pressure and needed an EKG. According to hospital records dated October 6, 2025-October 7, 2025, the chief complaint was R1 “not feeling well, GWK, sleeping more than normal, dizziness x a few days. Patient from Brookdale. Patient saw cardiologist this AM, BP was low at the clinic”. Hospital records indicated that R1 was diagnosed with hypotension likely secondary to component of dehydration and antihypertensive medications. Hospital records indicated that they made adjustments to R1’s antihypertensive medication regimen. R1 was released from the hospital on October 7, 2025, however, R1’s responsible party did not return R1 to the facility. Allegation: Staff did not ensure resident had water resulting in dehydration According to hospital records dated October 6, 2025-October 7, 2025, R1 was diagnosed with hypotension likely secondary to component of dehydration and antihypertensive medications. Hospital records indicated that R1 was provided with IV fluids, due to diagnosis. Based on medication count, records reviewed, and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Allegation: Staff are not meeting resident’s dietary needs According to ED and staff (S1, S2, S3, and S4), the facility followed R1’s special diet plan as directed by their physician. R1’s physician’s orders indicated that they are on a low-carb diet and avoid sugary snacks and juices. LPA observed that the kitchen has a board that they utilize to inform all kitchen staff of what residents are on a special diet and the type of diet. Interviews with residents (R4 and R5) indicated that the facility is following their special diets and they don’t have any concerns. Allegation: Staff did not ensure privacy during visits Interview with ED indicated that there are several areas in the memory section as well as assisted living that residents can have private visits with their visitors. LPA toured facility and observed all areas available for private visits in memory care and assisted living. Interviews with R4 and R5 indicated that there are no issues with having private visits at the facility. Allegation: Staff did not ensure dishes were cleaned and sanitized Interviews with ED indicated that a cart goes to the kitchen from memory care to ensure dishes are sanitized. S1 indicated that clear clean cups are provided to residents for drinking. R4 and R5 indicated that all dishes provided to residents are clean. LPA toured the kitchen area and observed staff washing/sanitizing dishes. ED and S2 indicated that R1 had a personal water bottle provided by their responsible party, however, they typically don’t utilize personal water bottles in memory care. ED and S2 indicated that R1’s personal water bottle was not dirty and was not being used. ED, S1, and S2 indicated that they have self-serve water stations in both memory care and assisted living. They also indicated that residents are offered water from the stations or in disposable water bottles. ************************************************Continued on LIC9099-C********************************************* Allegation: Staff did not ensure resident had access to a telephone Interviews with R4 and R5 indicated that they have not needed to use the facility phone, but it is available, if needed. ED and S2 indicated that there were times when R1’s responsible party would call to speak to R1, however, R1 would be dining, napping, or may not want to talk. ED and S2 indicated that they would inform R1’s responsible party to call back. S2 indicated that majority of the time R1’s responsible party would call R1 would speak to them. S2 indicated that they would always inform R1’s responsible party if R1 was busy or didn’t want to speak on the phone. ED and S2 indicated that they always have a phone available for residents. Based on interviews conducted, documentation obtained, and observations made, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.