complaint·December 22, 2025

It was also alleged that staff did not respond to resident's call button in a timely manner. It was reported it takes 30-45 minutes for staff to respond to Resident #2 (R2). A review of R2’s call button response log for October 2025 indicated some response times from 30-40 minutes. A review of Resident #6 (R6)’s call button response log for October 2025 indicated some response times from 30-65 minutes. Staff were not responding to residents in a timely manner. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Kimberly Garcia whose signature below confirms receipt of these rights. It was also alleged staff are physically abusing residents. It was reported Resident #1 (R1) and Resident #2 (R2) were being physically abused by staff and sustained bruises . The residents interviewed denied being abused by staff. Residents admitted they had bruises but were not certain how they were sustained. Residents explained they bump into things and take medications that increase risk of bruising. However, they did not believe staff would hurt the residents. Staff denied abusing residents. It was also alleged staff do not have background clearances and are currently working at the facility. A review of Guardian indicated two individuals were “in process”, meaning the individuals were not eligible. LPA confirmed that only one (1) of the two (2) individuals were actively working at the facility. The Human Resources (HR) staff explained they do not allow individuals to work in the facility unless they are fingerprint cleared and associated to the facility. HR staff explained that the individual working, Staff #1 (S1) has been employed for over 15 years, reflected in Guardian as a permanent employee, and they had the Department of Justice clearance document dated 09/07/2010 on file. Staff #2 (S2) have not begun employment at the facility. HR explained that years ago they had a change within their system, and they believe there was a glitch in Guardian. HR staff stated they contacted Community Care Licensing and were advised that S1’s documents were no longer uploaded to Guardian, possibly due to system errors. HR was advised to re-fingerprint S1 and upload the documents to Guardian. S1 was re-fingerprinted and cleared on 11/14/2025 and re-associated to the facility. S1 was employed for over 15 years, had eligible clearance, and documented as a permanent employee. There have been multiple issues with the Guardian system, which the Department is overseeing. It was also alleged that staff improperly transfer residents causing bruises. Residents that require transfer assistance were Interviewed. Those residents confirmed they are being transferred by staff accordingly and have not sustained any bruises while being transferred. Staff interviews also confirmed residents are not sustaining injuries during transfers. The Director of Assisted Living explained some residents are on medications that can increase the risk of bruising, such as blood thinners. A review of staff records reflected the facility conducts Orientation training that must be completed prior to working independently with residents. Some of the orientation training topics are transfer and lifting, and use of mechanical lifts. The facility provides ongoing training on lift assistance. The facility’s last training on transfers was conducted and documented on 10/09/25. The facility staff are trained on how to lift and transfer residents without causing injury. Continued on LIC 9099C. It was also alleged staff are withholding resident's medications. It was reported Resident #1 (R1) and Resident #3’s (R3) medications were withheld. It was unknown which medications were being withheld. A review of both residents Medication Administration Records indicated medications were given as prescribed, none were withheld. Staff interviews stated medications were not withheld from residents. R1 and R3 were interviewed and confirmed they were receiving their medications as prescribed. It was also alleged staff did not provide the resident with clean bed linen. It was reported residents are sleeping on the mattress without a sheet. On 11/05/25, LPA observed multiple resident rooms. All rooms inspected had clean linen present on beds. Resident interviews confirmed they are provided with clean linen weekly and more if needed. Staff confirmed residents linens are laundered weekly and more if needed. Resident beds contained appropriate bedding. It was also alleged that staff did not obtain medical attention for resident in a timely manner. It was reported Resident #3 (R3) was in pain and grimacing, and the nurse on duty was contacted to assess R3. It was reported the nurse advised staff to dispense R3’s already prescribed pain medication and see if it took effect, instead of sending R3 out for evaluation. It was also reported that R3 went to the hospital and was diagnosed with a lumbar fracture. However, review of R3’s medical records indicated R3 was admitted to the facility with the lumbar fracture. R3 was interviewed and denied any delay in medical care and reported they were pleased with the facility and staffing. It was also alleged staff did not keep facility free of odors. It was reported odors were coming from the third and fourth floor trash rooms, the main floor restrooms and an odor from Resident #4 (R4). It was alleged R4 had a stage 2 wound that was infected causing an odor. R4 was not interviewed as they passed away. A review of R4’s records did not identify any stage wounds. R4 had minor wounds, but none were pressure injuries. Also, R4’s hospice records did not indicate any signs of infection. Outside source reported the third and fourth floors trash rooms had odors coming into the hallway due to the facility not emptying it on a regular basis. However, staff confirmed it’s emptied every shift. Also reported, the main floor bathroom had an odor emitting into the hallway. Continued on LIC 9099C. On 11/05/25 and 12/08/25, LPA observed the third and fourth floors and the main floor bathroom, there were no odors. Outside sources that visit the facility were interviewed and confirmed there were no odors. Staff interviewed also confirmed there were no odors on the third and fourth floor trash rooms and they are emptied each shift and more if needed. Staff have not witnessed any resident’s with odors such as signs of infection. Staff also stated the main floor bathroom is for residents and public use. It was also alleged that staff did not ensure the resident's oral hygiene care needs were met. It was reported Resident #5 (R5) had canker sores on/in their mouth caused by lack of oral hygiene. R5 was interviewed and denied having any canker sores. R5 stated staff assist with oral hygiene when needed. Outside source reported that R5’s family is involved with R5’s oral care but the family does not follow through. The facility’s role is to assist or arrange dental care. However, the facility was not aware that the family was not following through with dental care. Management stated they will discuss dental care with the family. Staff denied observing canker sores on R5’s mouth. Staff explained if a canker sore is identified, they will notify the nurse for an evaluation. It was also alleged staff did not maintain a comfortable temperature. On 11/05/25 and 12/08/25, LPA observed a comfortable temperature, along with different regulated thermostats. Some resident rooms were warm and some were cool. LPA interviewed those residents, and they explained they were cold and preferred to keep their room warm. The residents are able to control the temperature in their rooms. Interviews with residents revealed they were comfortable with the facility’s temperature. Staff interviews confirmed the facility keeps the temperature regulated. Staff also commented that the residents prefer it warm, so they ensure the residents are comfortable. Staff reported that resident’s family members also adjust the thermostats in the room as well as the residents. The facility temperature was maintained throughout the facility, but the residents have the right to set their thermostats to any temperature they prefer. The Executive Director explained that if a thermostat isn’t working properly and they’re aware, the maintenance staff will address it immediately. It was also alleged that staff are intoxicated while providing care to residents. Interviews with staff confirmed they are not intoxicated while working. Residents also confirmed that they have not witnessed staff being intoxicated at work. The Executive Director (ED) explained there were no reports of staff being intoxicated at work or witnessed. The ED stated they would not tolerate or allow that behavior from staff. Continued on LIC 9099C. Lastly, it was alleged that staff did not keep the residents rooms free from bed bugs. On 11/05/25, LPA toured the facility and did not observe any bed bugs. The ED confirmed the facility did not have bed bugs. Resident interviews also confirmed they have not witnessed any bed bugs. Residents did comment they’ve been bitten by the mosquitoes outside. Staff also confirmed there have been no reported or witnessed bed bugs. Staff explained that some residents have sliding screen doors or patio doors in their room that leads to outside. Some residents like to keep the door open or step outside. There are mosquitoes in the area, and the residents have gotten bitten by mosquitoes, especially during the summer. However, there were not reports of bed bugs or bed bug bites. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Kimberly Garcia whose signature below confirms receipt of these rights.