complaint·April 10, 2026

(Continued from LIC9099) Regarding the allegation that Licensee did not ensure R1 had clean bedding. More specifically, a stained blanket was observed by the Reporting Party on 09/09/2024. Department interviews with Staff #1 and Staff #2 revealed acknowledgment that the facility’s linen inventory included worn or stained items. Department resident interviews revealed that multiple residents reported bedding and towels that were stained, worn, or frayed. Department LPA observations revealed worn linens in circulation during the visit. Photo evidence presented by reporting party showed visibly stained bedding. Regarding the allegation that Licensee’s staff did not treat resident with dignity. More specifically, a caregiver allegedly removed a spoon from a resident and stated, “You’re done now,” abruptly ending the resident’s meal. Department resident interviews revealed a credible eyewitness account confirming that the incident occurred and describing additional instances of abrupt or cold interactions by the same caregiver. Regarding the allegation that licensee did not keep the facility free of insects. More specifically, residents and photographs showed food left out after meal service, and multiple residents reported mosquitos, ants, and spiders inside Building 17 as well as main dinning area. Photo evidence supported that food remained out long after meals in November 2024. Department interviews with Staff #4 revealed awareness of mosquitos and use of a UV insect device in at least one room. Department resident interviews revealed repeated observations of mosquitos, ants, spiders and flies over time. Department LPA observations confirmed exterior doors to Building 17 were propped open and food remnants were left out, contributing to pest presence. LPA observation on 4/10/2026 Blue light pest control traps on the walls of the main dining area. Observation also revealed large sliding glass doors that lead into the common/dinning building and may contribute to insects entering the building. Based on relevant interviews, LPA observations, records review, and photo evidence, the preponderance of evidence has been met that the above violations occurred and are therefore SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22 (see attached LIC 9099D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. (Continued from LIC9099) Regarding the allegation that licensee did not meet R1’s incontinence care needs, Department interviews with staff revealed no double padding practices, and residents did not report issues with their own care. Department records review revealed documentation did not indicate inadequate incontinence care. Photo evidence showed saturated items but lacked context linking the condition to facility practice. Regarding the allegation that dressing/bathing needs were unmet, Department interviews with staff and residents revealed consistent showering practices, and records review revealed shower logs indicating missed care. Interviews with Residents did not indicate concerns with dressing or bathing. Regarding the allegations related to dietary preferences, activities, medication administration, centrally stored medications, pharmacy selection, staff health, and staff communication ability, Department interviews with staff revealed no confirmed violations; Department resident interviews revealed no consistent concerns; Department records review revealed no documentation supporting the allegations; Department LPA observations revealed no concerns. Based on interviews, direct LPA observations, and records review, the preponderance of evidence does not exist to prove that the alleged violations occurred; therefore these allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Adrian Guillen, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.