Complaint·October 15, 2025

According to R1, they had to tell S1 not to scream at resident #2 (R2) who is unable to defend themselves. R1 said that they informed the Licensee and their daughter. According to R2, they were able to understand the questions and answer them in small words and were able to articulate and scream how S1 would scream at them. While LPA spoke with them, they seemed in an altered state and their eyes started to tear up. LPA was able to inquire how they are currently being treated, and they were able to say they were being treated better. Resident #4 (R4) did confirm that S1 did yell at everyone. According to resident #3 (R3), they were treated fine and S1 did not yell at them. Resident #5 was unable to be interviewed as they were unable to hear well and would change the conversation when LPA asked them questions multiple times. According to staff #2 they confirmed S1 would yell at the residents. Staff and residents did confirm that S1 was hard of hearing which Licensee confirmed. Licensee did inform LPA that S1 was hard of hearing and had vision issues. LPA inquired if they had any PCP notes for the staff that indicated they had any issues with their hearing and they did not. Licensee said that when they had asked S1 about yelling at residents they had denied they yelled at them. S1 had informed Licensee that they were unable to hear. According to staff #3 and 4 (S3 and S4), they had not heard any staff yell at residents. According to S5 they had observed S1 being burnt out the last few weeks when they would speak to them but did not observe S1 yelling at residents. It was specifically said that staff were unable to administer medications as prescribed. The facility was unable to provide a medication profile sheet for R1, but they did have a MAR from R1s pharmacy. The facility had just recently received their MAR but were using their own medication log. LPA was unable to obtain the accurate medications R1 was to take but was able to compare the medications to the pharmacy MAR and the facility MAR. There were discrepancies found during the review. The pharmacy MAR did not have three medications the facility had on their medication log and in R1s medications that are being administered. There was one medication that the bubble pack and the facility MAR had as a PRN, but the pharmacy log had the medication being administered two times daily. The pharmacy MAR had a medication that the facility MAR and the facility did not have. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and resident interviews, and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Licensee Bessie Pascual. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Licensee Pascual at the conclusion of the visit. The signature below confirms the receipt of these documents. They believed that R4 had taken them as they had previously taken their food items that are on the facility cub board. According to S2, they were informed that R1 had missing hats for a few days and decided to look for them alongside R1. S2 had found the hats in their assigned closet under their television and the rest behind their television. According to R1, nothing further was taken. R1 said that they keep their food items in their room, which LPA observed and confirmed. According to R1 they had bug bites prior to the facility being tented. LPA inquired if they had any bites after they had returned and they denied having any new bug bites on them. LPA confirmed with staff #2 and Licensee that the facility had been tented within the last month, between 09/18 – 21/2025. Licensee said that they had to remove the pesticides from the facility as the bi-monthly services were inadequate and there were still bugs around. Licensee said that so far they had not see any bugs since their return. It was specifically alleged that the food they only eat is a peanut butter and jelly sandwich with a salad for dinner. According to R1, they are fine with the food they eat at the facility. The Licensee recently took them to the store to purchase some food, snacks and hygiene products they wanted. They said that the food there is okay but better than the last place they lived. According to R2, they do like the food at the facility and had no issues with it. They like eating meatballs and spaghetti. According to R3, they liked the food especially pizza nights which they have weekly and eating pancakes. According to R4, they used to eat a lot of Filipino foods, but no longer eat that and currently eat cereals, hard boiled eggs, tea and coffee which is better than before. According to S2 and S3 they assist with meal preparation. S2 cooks the food and they attempt to make the meals that the residents prefer such as french toast, pancakes, coffee, tea, cereals, oatmeal, eggs, beef stew and other meals they prefer. LPA observed that the facility did have two refrigerators and pantry which held sufficient food items. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Licensee Bessie Pascual. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Licensee Pascual at the conclusion of the visit. The signature below confirms the receipt of these documents.