complaint·April 21, 2026

(Cont. from LIC 9099) Regarding the allegation that the licensee did not meet residents' incontinence care needs, it was alleged that overnight coverage left residents soiled and wet overnight. Interviews did not corroborate the allegation, as staff and residents consistently stated that residents are changed every two(2) hours or as needed, overnight and throughout the day. Staff who worked the morning following the alleged incident reported that residents were changed promptly at the start of their shift and that residents had a normal amount of overnight incontinence consistent with a typical 2-hour window. Residents interviewed reported that they are changed regularly and do not remain wet or soiled for prolonged periods. Some residents were unable to be qualified as valid historians for interview due to cognition. Records reviewed of the facility’s brief-changing logs from past months consistently showed routine incontinence checks documented every 2 to 4 hours. Review of current residents’ care plans indicated that residents requiring incontinence care or hospice care are to be changed as needed and assisted with toileting every 2 hours, with service boxes checked to indicate provided care. LPA observed multiple resident rooms that contained adequate incontinence supplies, including briefs and wipes. Regarding the allegation that the licensee did not meet food service requirements, it was alleged that residents at the facility were not receiving dinner. Interviews did not corroborate the allegation, as interviews were consistent in reporting that meals are provided three times daily and that residents have not experienced missed meals. A resident interview stated that meals are served regularly, and they have never missed a meal since moving into the facility. Staff interviews further confirmed that breakfast, lunch, and dinner are prepared and served daily, with meals adjusted based on residents’ schedules and preferences. Staff reported that refusals are documented and that alternative meals or snacks are offered at any time residents request them. Staff also reported that dinner is always provided, and they were not aware of any incidents in which a resident did not receive an evening meal. Records review supported staff statements. Review of food purchase receipts from April 2026 showed multiple groceries purchased across various food groups. LPA observations revealed fully stocked refrigerators and freezers with no expired food noted. Based on interviews, observations, and records review, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. An exit interview was conducted with Administrator Linda Cruz and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.