complaint·January 14, 2026

(Continued from LIC9099) Regarding the allegation, the Licensee did not ensure that the staff were associated with the facility. More specifically, Staff #1 does not have Department background clearance and is employed at the facility. It was discovered through Department interviews with staff and residents, as well as records reviews. Staff #1 (S1) is currently employed at the facility. Review of the Department’s background clearance database revealed S1 was not associated to the facility and did not have a background clearance. Based on the evidence obtained, the deficiency was cited in an LIC 9099-D form. An immediate five-hundred-dollar ($500) civil penalty was assessed in an LIC 421BG form. Regarding the allegation, Licensee did not keep medications stored in their original packaging. More specifically, It was reported that staff fill medication containers designated for residents and place the medications into 7-day pill organizers. During the facility tour LPA observed medications being stored in plastic containers with different sections for morning, noon, evening, and bed time. An interview with Staff #2 (S2) revealed that S2 transfers medications into the corresponding time residents are supposed to receive their medication. These medications were not stored in the original medication packages. LPA explained to the licensee that medications must not be transferred into different containers in this way and in accordance with licensing guidelines must stay in their original packaging. Based on evidence obtained , the licensee did not store medication in original containers, the deficiency was cited in an LIC 9099-D Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D) and an immediate civil penalty was assessed. A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Licensee Lisa Sayre, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099) Regarding the allegation that staff did not provide incontinence care to residents. More specially, It was alleged that staff failed to provide timely incontinence care to R1 as outlined in the care plan. Department interviews with staff revealed inconsistent responses—some staff stated care was provided as required, while others were unsure or gave conflicting accounts. Department interviews with outside sources indicated they had not observed any issues related to incontinence care for any residence. OS1 reported frequent visits to the facility, including body checks for R1, and stated they had not noticed any urine odors in the facility or from other residents. Regarding the allegation that staff did not reposition bedridden resident(s) per care plan. More specifically, it was alleged that staff failed to reposition R2 according to the care plan schedule. Department interviews with staff revealed that all staff agreed they were following repositioning schedules and care plans, and that R2 was assisted out of bed almost daily. Department interviews with outside sources indicated they had not observed any problems related to repositioning. They further reported frequent visits to the facility and noted no skin issues concerning R2. Regarding the allegation that staff #3 (S3) may have consumed alcohol while at the facility. Department interviews with staff indicated they did not witness S3 providing care while under the influence. Department interviews with staff indicated they did not observe S3 providing care while impaired or under the influence to a degree that would affect job performance, safety, or effectiveness, as prohibited by CCLD regulations. Interviews revealed that alcohol was present during a celebratory events at the facility, and some staff reported witnessing brief toasts. There was no indication that any staff, including S3, were impaired or that resident care was negatively impacted. Department interviews with outside sources indicated they had not observed any staff appearing impaired or under the influence of alcohol Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are UNSUBSTANTIATED . An exit interview was conducted with Licensee Lisa Sayre to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.