Complaint·January 20, 2026

[CONTINUED FROM LIC 9099] The Complainants said between September 2025 and the filing date of the complaint (01/12/2026), R1 in practice needed help with mobility/transferring, personal hygiene tasks, and managing medical appointments, but facility staff were not consistently providing R1 this needed help. They also said R1’s room was malodorous and messy/cluttered, to include potential tripping hazards on the floor. Review of R1’s care records showed R1 diagnoses included Schizoaffective Disorder and Congestive Heart Failure. During his own 01/20/2026 site visit, LPA met and interviewed R1 inside their private apartment. R1’s room was malodorous with a strong fecal smell. LPA observed R1 did not flush their toilet after a bowel movement, and there was fecal staining around R1’s toilet seat, on the outside of R1’s toilet bowl, on R1’s bathroom floor, and on the carpet of R1’s bedroom. While R1’s clothes were clean during this visit, R1’s hair was dirty/unkempt, and their facial hair was about an inch-long and messy. While R1 was reluctant to pay more money for a higher level of care, R1 statements to LPA also revealed that they currently needed 1-Person Assistance from staff with Mobility/Transferring, Dressing, Grooming, Bathing, Bathroom Assistance, Status Checks, Medication Management, and Daily Housekeeping. Interview of facility management, corroborated by R1’s facility care records, showed: When R1 first moved-in on 11/13/2020, Licensee assessed R1 as then needing help with Transferring (Minimal Assist), Bathing (Standby Assist Once Per Week), Status Checks (Three Times Per Day), Medication Assistance, and Once-Per-Week Housekeeping, and Licensee prepared R1’s care plan accordingly. Then on 03/03/2021, Licensee reassessed R1, determining R1 now needed zero help with personal care tasks or status checks, beyond Medication Assistance and Once-Per-Week Housekeeping, and Licensee updated R1’s care plan accordingly. Then on 09/22/2025, Licensee again reassessed R1, determining R1 now needed help with Status Checks (Three Times Per Day), Medication Assistance, and Once-Per-Week Housekeeping, and Licensee updated R1’s care plan accordingly. Then on 01/19/2026, Licensee again reassessed R1, determining R1 now needed help with Mobility/Escorting (Limited), Bathing (Standby Assist Twice Per Week), Status Checks (3 Times Per Day), Medication Assistance, and Daily Housekeeping, and Licensee updated R1’s Care Plan accordingly. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] CCLD received the complaint on 01/12/2026. While Licensee reassessed R1’s care needs as recently 01/19/2026, the level of care that Licensee determined still fell short of R1’s true, current care needs. Interviews of facility management and multiple visiting outside medical professionals (who were assigned to R1) showed that during the complaint timeframe, Licensee did not provide the level of hygiene care that R1 actually needed. Interviews showed Licensee did connect R1 to professional organizers/movers and a storage unit to reduce the clutter in R1’s bedroom during the complaint time frame. However, during LPA’s own 01/20/2026 visit, he saw multiple objects still on R1’s bedroom floor which were potential slip/trip hazards. Interview of R1 and manager, corroborated by past self-submitted LIC624 Incident Reports received at CCLD from Licensee, showed R1 had a history of falls. [During today's visit, LPA directed Licensee’s staff to provide immediate housekeeping services for R1's bedroom.] Per interview of facility management, Licensee is currently assisting R1 with managing their medical appointments. Based on records and interviews, a preponderance of evidence exists to show that at least during the complaint time frame, Licensee did not provide the needed level of care to R1 and that Licensee did not ensure R1’s room was safe and healthful. Both allegations are therefore Substantiated. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Resident Services Director Ashley Baino-Jaimes, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. A duplicate set of these same documents was E-mailed to Executive Director Julia Lopez.