Complaint·June 5, 2025

Continued from LIC 9099-A) It was alleged staff retaliated against a resident.  More specifically it was alleged  Staff #1 (S1) spoke of retaliating against resident #1 (R1) by stating they are trying to move R1 from the facility. Although the reported party stated they observed S1 speaking about retaliation. Staff interviews and interviews with residents did not corroborate the allegation, as staff consistently denied witnessing any form of retaliation by S1 to residents. Resident interviews, including R1, denied witnessing any form of retaliation by S1 to residents. It was also alleged staff did not meet residents needs and staff did not meet resident's incontinence needs. More specially, licensee staff did not help with R1 for over an hour after R1 request with incontinent needs, clothing changing and providing breakfast service.  A review of R1 needs and service (dated 11/26/2021) reveals  toileting and grooming as independent. Additionally resident will remain as much independence as possible with bathing and showering.  The report further states the R1 will retain ability to partially dress self and staff will help with balance while dressing. R1 was interviewed around the time of the complaint and no evidence could be found in the interview to support the allegation. Records review as well as interviews with the licensee, staff, and medical personnel, were conducted and revealed that although some residents required more incontinence and toileting care, there wasn’t any documentation of concern for neglect, abuse, or non-accidental injuries were noted. Based on the Department's investigation, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted with Administrator Nora Garza to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit . ( Continued from LIC9099) (Pages 2 of 3) According to records review R1's physician report reveals they can communicate and have no issues with confusion or depression. R1's needs and service plan (dated 1/14/2022) states they have stand-by assistance, with bathing, hair care and personal hygiene. It was alleged that facility staff was not following COVID-19 protocol. More specifically, licensee management team kept positive COVID-19 cases from care giving staff, residents, and families of residents . Care giving staff and resident were interviewed around the time of the complaint and revealed that residents and staff  had tested positive for COVID-19 and stated that the facility did follow the COVID-19 protocol by not informing care staff or residents of positive COVID-19 cases. Records review revealed COVID-19 related incident reports were not submitted to CCL from 12-21-2020 to 2-8-2021.   Information gathered during staff and resident interviews indicated that staff facility-wide policy, supported by CCLD PIN recommendations, was to  communicated to families in writing, report infection disease outbreaks to CCL, and adhere to infection control personal protective equipment guidelines. Records review, staff interviews and resident interviews gave corroborating evidence that Licensee management staff did not follow CCL infection protocols. It was further alleged staff spoke inappropriately to resident. More specifically Staff #1 (S1) yelled at R1 while standing outside their room entrance.   A written statement by R1 and resident #2(R2) reveal S1 used statements towards R1 that were hurtful.  R1 statement revealed when S1 discovered R1 had hired an outside agency to conduct mold testing, S1 approached R1 at their door (#106). S1 was angry and accused R1 of not reporting mold issues to maintenance. R1 then rebutted and tried to explain they reported the mold to maintenance  three (3) different times yet the mold was not removed only covered up.  R2 written statement revealed they witnessed R1 crying while S1 was yelling " this is my house and they (R1) have no rights here" Interview with current Administrator confirm S1 is no longer working at the facility. (continued on LIC9099-C) ( Continued from LIC9099-C) (Page 3 of 3) It was further alleged the facility was in disrepair.  More specifically, R1's two living spaces within a two story building (room 106) had flood soaked walls and carpet, that was not addressed by facility and caused mold.  A written statement sent to CCL by R1 reveals they reported the flooding to the facility and the facility had not addressed the flooding for weeks. Musty odor was observed by residents and an independent mold inspection was performed on 1/2/2022 in room #106.  Inspection yielded high levels of mold and mold growth was present.   According to Outside Source #1(OS1) they witnessed the facilities director and executive director speaking of the  mold in room #106. According to the Centers for Disease Control, indoor mold has been proven to cause upper respiratory infections ( www.cdc.gov ). Therefore, the present mold is a health and safety concern for the clients in care. Based on interviews, written correspondence record review and outside source reports the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The allegation is, therefore, Substantiated. Three (3) deficiencies were cited per the California Code of Regulations, Title 22 (refer to the LIC 9099-D pages). A Plan of Correction was jointly developed with the Licensee.An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Nora Garza whose signature below confirms receipt of these rights.