Complaint·August 7, 2025

Records review revealed that the facility staff self-reported the hot water outage to residents and residents’ representatives via email communications. Interviews with internal sources revealed that there was an issue with the water heater’s valve and it took a few days to obtain a repair. During the hot water outage, staff were transporting residents to a sister facility to obtain showers, and the facility bought a portable shower. Interviews with internal and external sources and records reviewed corroborated that the facility was without hot water for multiple consecutive days. Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. According to the allegations received, staff were seen being physically inappropriate with a wheelchair bound resident by doing wheelies with their wheelchair while the resident was present. It was alleged that staff were unprofessional in the way they spoke to residents and had made a joke about a resident’s incontinence management. It was alleged that Resident #1 (R1)’s pre-operation instructions were not followed by staff and that a physician on-site at the facility tried to enter a resident’s bedroom without permission. It was also alleged that a staff member went through a resident’s purse without permission and that a health insurance program was billed for Resident #2 (R2)’s physician visits at the facility while R2 was not present at the facility. Interviews with internal sources revealed that some wheelchairs bound residents have difficulty raising their feet doing ambulation assistance from staff. Therefore, in the process of aiding residents’ staff may lift the front wheels off of the ground slightly to back up the resident and aid them with foot placements. Interviews with internal and external sources did not reveal a concern for staff being physically abusive nor handling residents inappropriately. Interviews with internal and external sources also did not reveal a concern for unprofessional or verbally abusive staff. Interviews did not reveal a scenario where staff made jokes about a resident’s incontinence management. Per record review, R1 was scheduled for surgery on January 22, 2025, and per the pre-operation instructions, R1 was instructed to receive a hot shower. Interviews and records reviewed revealed that during that time period, the water heater was broken, and the facility did not have hot water. R1 was transferred to a different location by their representative and was provided with a caregiver to shower R1 as instructed. Records reviewed revealed that R1’s representative was compensated by the facility in order to follow the physician’s instructions. Interviews with internal and external sources did not reveal that a physician entered R1’s room without knocking and announcing themselves prior to entering. Interviews revealed that if staff do not get a response from a resident, they will enter to check on the well-being of the residents. [Continued on LIC9099-C] Review of R1’s progress notes dated December 28, 2024 revealed that R1 exhibited an aggressive behavior after stating they did not receive their bedtime medications. Interviews and records reviewed revealed that R1 was asked to check their purse for the bedtime medications, and when the medications were not located, R1 brought the purse over to staff to have them check. Interviews and records reviewed did not reveal that R1’s purse was looked through without R1’s consent. Interviews and records review did not reveal that the licensee is billing for services not provided. Interviews revealed that the physicians that come to the facility are contracted and not employees of the facility. Thus, the billing between the health insurance program and the physician’s visit is not billed through the licensee. Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude that staff are physically and verbally abusing residents, staff did not follow physician instructions for resident, staff did not accord resident privacy, staff did not safeguard resident’s personal belongings, and the licensee is billing for services not provided. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.