complaint·April 12, 2026

This report supersedes the report created 4/11/26 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Staff did not provide a healthful accommodation to the residents The details of the complaint alleged that facility was not clean and sanitary On April 11, 2026, at approximately 9:00 a.m., during a health and safety inspection of the facility, the Department conducted a random check of ten (10) resident rooms. The Department observed that (10) out of (10) rooms had carpet stains and trash scattered throughout. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Susan Caccam/Facility Administrator. This report supersedes the report created 4/11/26 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Staff did not properly groom a resident The details of the complaint alleged that facility staff did not properly dress (R#1) with the appropriate clothes On April 11, 2026, at approximately 10:00 am, during an interview with (R#1), the Department observed that (R#1) was dressed in clean clothing appropriate for the day’s weather. The Department asked (R#1) who selected the clothing they were wearing, and (R#1) stated that they chose the clothing themselves. On April 11, 2026, during an interview with the facility administrator (A#1), (A#1) stated that facility staff are trained to select appropriate clothing for residents based on current weather conditions. (A#1) further stated that when residents have the ability to choose their own clothing, staff allow them to do so while providing guidance as needed. In addition, (A#1) was also asked about the systems in place to ensure residents have access to their personal clothing and that staff utilize clothing provided by family members. (A#1) stated that each resident has their own closet where personal clothing is stored. According to (A#1), facility staff place clean clothing in the residents’ closets after laundering to ensure items are available and accessible. On April 11, 2026, during interviews with residents in care (R#1 through R#7), residents were asked whether staff assist them regularly with grooming, including dressing, brushing hair, and bathing, and whether the assistance is appropriate for their needs. (3) out of (7) Residents stated that they perform their own dressing and grooming; however, they observed that staff assist other residents who require help. In addition, residents were also asked if they had ever been dressed in clothing that felt uncomfortable or inappropriate for the weather. (7) out of (7) residents stated that they had no concerns and that everything was appropriate. Evaluation Report continues LIC 9099-C This report supersedes the report created 4/11/26 and the findings will remain unchanged. On April 11, 2026, during interviews with facility staff (S#1 through S#3),(3) out of (3) facility staff stated that they assist residents with showers, changing clothes, and escorting residents to the dining room as part of their grooming and dressing responsibilities. Staff reported that the level of assistance provided varies depending on each resident’s needs and level of independence. In addition, staff were also asked how they ensure that residents are dressed in a manner that is comfortable and appropriate for their needs, including weather-appropriate clothing. (3) out of (3) staff stated that they offer residents multiple clothing options and encourage residents to choose their preferred items when possible. Allegation: Staff mishandled a resident's personal belongings The details of the complaint alleged that facility staff did safeguard (R#1)’s personal belongings On April 11, 2026, at approximately 2:00 pm, during the records review, the department observed a copy of (R#1) client/resident personal property and valuables or LIC 621 dated 9/26/23. The department noted that (R#1) had listed on the form (4) shirts, (4) pants, (1) purse, (1) pair of glasses, (1) jacket, and (1) blanket. During the health and safety of (R#1)’s room, the department observed the items listed on the LIC 621 in (R#1)’s dresser. On April 11, 2026, during an interview with the facility administrator (A#1), (A#1) stated that the resident’s clothing was not missing. (A#1) explained that due to (R#1)’s cognitive impairment, the facility keeps additional clothing for (R#1) stored in another section of the building. (A#1) reported that staff maintain a rotation system in which a portion of (R#1)’s clean clothing is placed into (R#1)’s chest of drawers and closet, and once those items are used, staff replenish the drawers and closet with more clean clothing from the stored supply. In addition, when asked how the facility ensures residents consistently have access to their personal clothing and how staff maintain accountability for resident property, (A#1) stated that (R#1) has a chest of drawers and a closet inside the resident room. Evaluation Report continues LIC 9099-C This report supersedes the report created 4/11/26 and the findings will remain unchanged. (A#1) further stated that staff are responsible for placing an adequate amount of clothing in these areas and refilling them as needed after items are worn or laundered. On April 11, 2026, during interviews with residents in care (R#1 through R#7), (7) out of (7) residents stated that had not experienced issues with personal clothing or belongings going missing. When asked, “Have you ever had any personal clothing or belongings go missing or not returned to you?” each resident responded with statements such as, “Not that I can think of.” Residents were also asked whether they felt staff keep track of their belongings and return clothing after it is washed. (7) out of (7) residents stated that they believed staff manage clothing appropriately. On April 11, 2026, during interviews with facility staff (S#1 through S#3),(3) out of (3) facility staff stated that that they follow established procedures to keep track of residents’ clothing and personal items. When asked, “What steps do you take to keep track of residents’ clothing and personal items?” staff reported that during the admission process, an inventory list is completed which documents the residents’ personal belongings, including clothing. In addition, when asked how staff handle situations where a resident’s belongings cannot be located, (3) out of (3) stated that, due to serving residents with cognitive impairment, the facility often keeps residents’ clothing in the laundry room to ensure clothing does not become misplaced. Staff reported that when a resident needs clothing, they provide the items directly from the supply kept in the laundry area. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Susan Caccam/ Facility Administrator.