Complaint·May 29, 2026

(Continue from LIC9099) Background Information Review of R1’s admission agreement and other relevant records did not disclose any diagnosis or condition related to dementia. Records reviewed during the investigation confirmed that R1 moved into the facility in April 2025 and voluntarily moved out in October 2025, residing at the facility for approximately six months. Multiple interviews conducted during the investigation described R1 as alert and oriented to person, place, and time, capable of advocating for themselves, and considered a credible witness. Records and interviews further disclosed that R1 had a history of verbal disagreements with staff and other residents and was frequently described as difficult to redirect. Staff and outside sources consistently described R1 as unhappy living at the facility. During an interview conducted on May 28, 2026, R1 stated that S1 spoke inappropriately to them and threatened eviction. R1 alleged that on or about October 1, 2025, S1 told R1 “to get out by the end of the month or else they would wish they had.” R1 also stated that S1 brought dogs into the facility and that during one incident, a dog approached R1, causing R1 to lift their legs to avoid contact. According to R1, S1 yelled across the room, “Don’t you dare kick my dog.” R1 stated they were attempting to move away from the dog and denied attempting to kick it. R1 further alleged that following this incident, S1 instructed staff to withhold certain services, including clean bedsheets, timely meals, and shower assistance. However, during the investigation, R1 was unable to provide specific dates, times, or examples when services were allegedly not provided. R1 stated that residents and staff witnessed the incident but was unable to recall names or additional identifying information. R1 stated that S2 advocated on their behalf and often intervened during disagreements involving R1 and S1. On May 28, 2026, during an interview, S2 recalled assisting with de-escalating situations involving R1 and staff or other residents in general. S2 stated that R1 frequently became upset during interactions with others and that de-escalation interventions were often effective. However, S2 denied ever witnessing or hearing S1 threaten, mistreat, or speak inappropriately to R1. (continue at LIC9099C) (continue from LIC9099C) Interviews conducted with residents, staff, responsible parties, and outside sources did not produce corroborating evidence to support the allegations. During an interview, S2 stated that staff made significant efforts to accommodate R1’s preferences and care needs. S2 explained that R1 requested showers at approximately 5:30 a.m., and the facility accommodated the request by arranging for designated staff to arrive early once or twice weekly. Review of shower schedules and care records confirmed that R1 received showers twice weekly, consistent with R1’s service plan. Interviews with R1’s responsible party did not disclose concerns regarding the care or services provided by staff. The responsible party acknowledged staff efforts to accommodate R1’s requests and needs. Records reviewed during the investigation confirmed that R1 voluntarily moved out of the facility on October 20, 2025. There was no evidence that R1 was served with a 30-day eviction notice, and no corroborating evidence was obtained indicating that staff threatened eviction. It was also alleged that staff failed to appropriately intervene during altercations between residents. However, no specific dates, times, or details regarding alleged resident altercations were provided during the investigation. Interviews conducted with residents, staff, and outside sources did not disclose any incidents involving resident altercations. Additionally, a review of incident reports submitted to CCL during the relevant period did not disclose any resident-to-resident altercations. Staff interviews consistently indicated that direct care staff receive training regarding resident care, activities of daily living, and de-escalation techniques to ensure resident health and safety. Staff reported that care and supervision are provided in accordance with residents’ individualized service plans. Staff denied the allegations and stated they were unaware of any incidents involving inappropriate treatment of residents or unaddressed resident altercations. Interviews conducted with residents and responsible parties did not disclose concerns regarding unmet care needs. Residents and responsible parties stated that bedsheets were changed weekly or as needed when soiled, meals were served according to schedule, and shower schedules were followed in accordance with individualized service plans. (continue at LIC9099C) (continue from LIC9099C) During facility visits conducted on November 25, 2025, and February 11 and 25, 2026, resident rooms were observed to be clean and organized. Beds inspected during the visits contained clean sheets and linens. LPA also observed staff interactions with residents and did not observe concerns regarding staff conduct or resident care. Staff appeared attentive and responsive to residents’ needs. Additionally, sufficient staff were observed present during the visits to meet residents’ care and supervision needs. Based on observations, interviews, and record reviews conducted during the investigation, there was insufficient evidence to support the allegations that staff spoke inappropriately to R1, threatened eviction, failed to provide clean bedding, failed to provide meals in a timely manner, failed to provide bathing assistance, or failed to appropriately address resident altercations. Although R1 reported concerns regarding staff conduct and care, the allegations were not corroborated through interviews, records, or observations conducted during the investigation. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Business Office Manager, Ellen Arguello. A copy of this report, LIC811 Confidential Names List, and Licensee Appeal Rights (LIC 9058, 03/22) were provided at the conclusion of the visit.