Complaint·January 28, 2026

[CONTINUED FROM LIC 9099] Regarding the first allegation: The Complainant said Resident #1 (R1) relied on staff help for changing their clothes, but that Licensee’s staff do not regularly provide this help, as required. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] The Complainant said R1 relied on staff help with grooming (to include shaving), but Licensee’s staff did not regularly provide this help, as required. The Complainant said Resident #2 (R2) did not have the manual dexterity to peel an orange, and that Licensee’s staff would hand R2 whole oranges without peeling them, meaning R2 could not eat these fruits. According to the care assessments/plans which Licensee authored on R1 and R2, both residents were supposed to receive assistance with bathing (twice per week), dressing (twice per day), and grooming (twice per day). Grooming assistance included toenail and fingernail care. During his 01/14/2026 visit, LPA observed: R1 and R2 were in reasonably clean clothing. Neither person had foul body odor. The same was true for all other residents of the facility. However, R1 had unkempt facial hair around an inch-long. R1 had long/overgrown toenails. R2 had long/overgrown fingernails and toenails. Resident #3 (R3) also had overgrown fingernails. Interviews of staff and outside sources aligned to show: Those facility residents who could not bathe independently were typically assisted by staff with bathing twice per week, according to a facility shower schedule (which LPA obtained a copy of). Resident interviews widely corroborated that twice-per-week bathing help was provided, in practice. Almost half the time, R1 refused to be showered, despite repeated attempts/encouragement by caregivers, which was R1’s right to do. Multiple staff reported that R1 was not shaven because they had refused to be shaved. However, R1 expressed to LPA on 01/14/2026 that they preferred to be shaven, and that they would accept shaving help if it was offered to them, which LPA relayed to staff that same day. (On LPA’s return visit on 01/28/2026, LPA observed R1’s beard and moustache had been neatly trimmed/groomed.) Staff interviews showed mixed answers and a lack of general clarity among the caregivers as to who was responsible for residents’ fingernail and toenail care, and at what frequency such care should be rendered. R1 told LPA that staff indeed typically peeled and cut their oranges for them. Staff interviews widely corroborated this. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Regarding the second allegation: The Complaint said there have been a few occasions between August 2025 and early January 2026 when they observed no toilet paper available in a hallway bathroom shared by the facility’s residents. During his 01/14/2026 facility visit, LPA also observed that one (1) of the facility’s two (2) shared bathrooms had no toilet paper. LPA instructed staff to add more toilet paper that day. On LPA’s return visit on 01/28/2026, both bathrooms had toilet paper inside them. Based on records and interviews, a preponderance of evidence exists to show that at least during the complaint timeframe, Licensee did not meet residents’ personal care needs and that Licensee did not maintain toilet paper in bathroom. Both allegations are therefore Substantiated, and two (2) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee/Administrator Alex Limpin, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] LPA met privately with all (12) residents in care, finding two (2) did not have the mental ability to answer questions. LPA also interviewed two (2) managers and four (4) direct care staff. The Complainant said most of the time when either Resident #1 (R1) or Resident #2 (R2) pushed their call button, Licensee’s caregivers did not respond to it at all. [See LIC811 Confidential Names list for a description of select person identifiers used in this report.] During his 01/14/2026 visit, LPA tested the call buttons for R1 and R2, finding both devices were working and transmitting a signal to the med tech station, as expected. Of the ten (10) residents who could answer questions about this topic, six (6) said they were ambulatory and thus generally did not use their call buttons. Of the remaining four (4) residents, only one (1) complained of slow response time. Interviews of managers and caregivers aligned to show that caregivers aimed to respond to call signals as soon as they heard them (unless they were already in middle of providing care to another resident) and that caregivers generally worked as a team to timely meet such calls for service. The Complainant said during their 01/05/2026 visit, strong urine and fecal odors pervaded the facility (rather than being specific to any room or resident). During his own 01/14/2026 and 01/28/2026 visits, LPA did not smell odors of incontinence in facility common areas or resident bedrooms; the facility smelled fine. Of the ten (10) residents who could answer questions about this topic, nine (9) said the facility smelled fine to them, and one (1) did not have an opinion on the topic. Interviews of the managers and staff did not reveal evidence of the facility being malodorous. The Complainant said on multiple days between August 2025 and early January 2026, the floor of R1 and R2’s shared bedroom had trash/debris on the floor. They also said facility staff did not clean R1’s bedside table of food debris, and that on 01/05/2026, there was a fecal stain on R1 and R2’s window curtain. During his own 01/14/2026 and 01/28/2026 visits, LPA did not see trash/debris on the bedroom floor of R1/R2, or any other resident’s bedroom or common area. R1's bedside table was also clean. The facility’s walls were clean. Of the ten (10) residents who could answer questions about this topic, all ten (10) said Licensee’s staff kept the facility in a state of general cleanliness. Manager interview showed that on an earlier date, there was indeed a stain on the window curtain of R1/R2, but this was chocolate Ensure (not feces), and the curtain was soon changed out for a clean one. LPA reviewed a photograph of the curtain in question, taken on the date in question; the splatter patterning was more consistent with the Ensure explanation (i.e., it did not look like feces). [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] Complainant said on 01/05/2026, the facility temperature fell to around 53 F, because staff left both of the facility’s two (2) front doors ajar at night. During his own 01/14/2026 visit, LPA observed the facility’s temperature was in the low 70s (well-within in the required range described in regulation). LPA also observed that Licensee kept extra portable heaters on the premises and available to deploy to resident rooms, upon demand. Of the ten (10) residents who could answer questions about this topic: Nine (9) said the facility temperature was consistently kept comfortable. Resident interviews widely aligned to show that staff typically kept the facility’s two (2) front doors closed at nighttime. Multiple residents confirmed remembering heavier rainfall during early January 2026, but said the facility was kept warm with heaters. Only one (1) resident said the facility was often too cold (to include the date of LPA’s 01/14/2026 visit). However, this last resident also stated that when they felt cold, staff provided them with blankets. (LPA witnessed this resident using three blankets during his visit). When LPA returned on 01/28/2026, the facility was again at a warm and comfortable temperature. Interviews of managers and caregivers did not produce evidence of the facility being too cold, even during the earlier week that the Complainant had referenced. The Complainant said R2 was bitten by insects while inside the facility. During his 01/14/2026 and 01/28/2026 visits, LPA did not observe any live or dead insects inside the facility. Of the ten (10) residents who could answer questions about this topic: Eight (8) denied the facility having any insect problem. One (1) resident did not have a clear opinion on the topic. One (1) resident said they had been bitten by mosquitoes on their head and cheek, but they declined to let LPA look closely at their head, and LPA did not see any bites on their face. Interviews of a facility manager plus an outside source showed that at one point during the complaint period, this last resident received a visitor who brought a dog that laid on the resident’s bed. Upon receiving an allegation of an insect bite to said resident (prior to CCLD receiving the complaint), facility staff changed that resident's bed sheets and contacted the visitor to provide them notice and instruction. The available evidence cannot reliably establish that this visitor’s dog had fleas; even if their dog did, there is no evidence of Licensee culpability here. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] The Complainant said there was a period when R1’s hospital bed stuck out to the point that it obstructed their bedroom door from being closed. Interviews of managers, caregivers, and an outside source, along with video, showed: During late 2025, Licensee undertook a project to widen the doorframes of its residents’ bedrooms to make them more wheelchair-friendly. As part of this project, the shared bedroom door belonging to R1 and R2 was also widened. During the complaint period, R1’s/R2’s bedroom door could not be swung closed because it would contact the end of R1’s bed. After a few weeks, staff fixed the issue by rearranging/reorienting R1 and R2’s beds within the room to prevent blocking the door’s swing. Based on the specific circumstances and dimensions involved, CCLD concluded that the passageway into and out of R1’s bedroom was not blocked to the degree that people were materially slowed when coming in and out of the room. (However, the inability to close the bedroom door represented a privacy violation, which will be cited in a separate Case Management report.) Complainant said facility staff let R1 lay atop bedsheets that were dirty with food residue, rather than put clean sheets on R1’s bed. During his 01/14/2026 and 01/28/2026 visits, LPA briefly observed the beds and bedding of the twelve (12) residents in care, finding all were reasonably clean. Of the ten (10) residents who could answer questions about this topic, all ten (10) affirmed that staff consistently provided them with clean sheets and bedding. Residents widely reported that facility caregivers typically changed their sheets and pillowcases twice per week on their scheduled shower days, plus on request. Interviews of the managers and caregivers corroborated this. Based on records and interviews, a preponderance of evidence does not exist to show that that Licensee did not timely respond to resident(s)’ calls for assistance, that Licensee did not keep facility free of incontinence odors, that Licensee did not maintain facility cleanliness, that Licensee did not maintain comfortable facility temperature, that Licensee did not keep facility free of insects, that Licensee did not keep passageway free of obstruction, and that Licensee did not provide clean bedding. These seven (7) allegations are therefore Unsubstantiated, and no deficiencies were cited for them. An exit interview was conducted with Licensee/Administrator Alex Limpin , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.