complaint·October 17, 2025

Continued from LIC9099) Staff interviews revealed that hot water sometimes runs out during shower times, requiring staff to stop showers or sometime provide bed baths. Resident interviews confirmed that water temperatures were inconsistent, with some residents reporting cold showers. Water temperature readings were taken in 13 resident rooms across four buildings. Of those, 12 out of 13 rooms had hot water temperatures within the regulatory range of 105°F to 120°F. However, hot water was not consistently maintained within the required range, as confirmed by resident and staff interviews, which included missed bathing opportunities due to a lack of hot water temperature in showers. Based on relevant interviews and records review, the preponderance of evidence has been met that the 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). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Chris Neale, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued on LIC 9099C) Resident interviews revealed that one resident reported concerns regarding Staff #1’s tone and responsiveness. Other residents interviewed described Staff #1 as helpful and did not express concerns about her conduct. Department records review revealed no formal complaints or disciplinary actions against Staff #1. However, the lack of interviews with Residents #1 and #2 limits the department’s ability to fully assess this allegation. This allegation is unsubstantiated due to insufficient evidence. It was also alleged, staff did not meet residents’ dietary needs or serve food of good quality. More specifically, the Reporting Party (RP) stated that Resident #2, who is on a regular diet, was served pureed food, that portion sizes were inadequate, and that a resident was served half a hot dog on molded bread. The RP also stated that residents were not provided snacks between meals. Staff interviews revealed that portion sizes had recently been adjusted and that food is sometimes softened for easier chewing. Staff acknowledged occasional errors in diet type, particularly with new staff. Some staff described the food as mushy or cold, but noted that seconds were available upon request. Resident interviews revealed concerns about small portion sizes and food temperature. Some residents reported being able to request additional servings, though delays were noted. Department records review revealed that the facility uses measured scoops for portion control and a photo of a food sample from January 2024 showed balanced meals. A list of snack items available for purchase from the facility’s store was also reviewed. The concern regarding diet type mismatch could not be verified due to the lack of documentation or interview with Resident #2. This allegation is unsubstantiated due to insufficient evidence. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Chris Neale, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.