complaint·December 9, 2025

Regarding the allegation “Staff refused to assist resident with toileting” the department received photo evidence of Resident #2 which demonstrated R#2 lying in bed uncovered wearing only a diaper brief that went down below R#2 waist. In addition, photo also demonstrated R#2 blanket to be sitting on the floor next to a used diaper. Third allegation: Staff refused to assist resident with dressing. Regarding the allegation “Staff refused to assist resident with dressing” During the observation of photo evidence pertaining to Resident #2 LPA observed R#2 lying in bed uncovered wearing only a diaper brief that went down below R#2 waist and exposing resident. Photo demonstrated R#2 in a curled-up position undressed and without covers and or blankets. Based on the evidence gathered during the investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 regulations 87465(2), Incidental Medical and Dental Care, 87468.1 Personal Rights of Residents in All Facilities (a)(1)(2) & (3), from division 6, chapter, article 6, is, being cited on the attached LIC 9099 D. In addition, an immediate civil penalty of $500.00 was assessed, according to the Health and Safety Code 1548 (c). Furthermore, an additional civil penalty may be imposed by the Health and Safety Code 1569.49 (f). An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to the Facility Administrator at the conclusion of the visit. Regarding the allegation “Staff handled resident in a rough manner causing injury. LPA conducted a review of record upon the review of records LPA discovered that Resident#1 did not indicate to staff or report to staff that resident’s injury was caused by staff or that staff had handled R#1 in a rough manner causing an injury. In addition, LPA discovered that based on interviews R#1 reported the injury to staff. LPA conducted interviews with R#3-6 LPA went over the alleged allegation with residents and all denied being handled in a rough manner by staff. In addition, all residents also denied witnessing staff handling residents in a rough manner. LPA conducted interviews with S#2-5 LPA went over the alleged allegation with staff and all denied handling residents in a rough manner. In addition, S#2-5 also denied witnessing staff handle resident in a rough manner or causing injuries to residents in care. Third allegation: Staff left resident with soiled bedding. Regarding the allegation “Staff left resident with soiled bedding” Based on observation and the review if R#2 photo LPA could not determine if R#2 bedding was soiled. Based on image LPA could not determine if R#2 bedding was soiled as the image did not display R#2 bedding to appear wet. LPA conducted interviews with R#3-6 LPA went over the alleged allegation with R#3-6 and all denied being left on soiled bedding. LPA conducted interviews with S#2-5 LPA went over the alleged allegation with staff and all denied leaving residents bedding wet or soiled. S#2-5 informed LPA that the facility provides housekeeping who changes residents sheets and conducts laundry service once a week and or as needed. Based on corroborating evidence the department has determined that the above allegations are Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Ashely Willett.