Complaint·March 27, 2026

[Continuation of LIC9099: p.2 of 3] Resident #2’s (R2) LIC602 indicates that they have a cognitive condition but has the ability to communicate their self-care needs and follow instructions. Their physical health states that they need assistance with repositioning and transferring. They do have an assistive device to assist with transferring. Due to their cognitive ability, they are unable to manage their own medications, lack hazard awareness, and are disoriented. Resident #3’s (R3) LIC602 shows that they are cognitively sound, but require assistance with repositioning and transferring. R3’s self-care capacity demonstrates that they are able to communicate their needs and follow instructions. They do have episodes of confusion and lack hazard awareness. R3 is unable to manage their own medication. According to the LIC602 for resident #4 (R4), they do display mild cognitive impairment and are confused/disoriented, but has the ability to follow instructions and communicate their needs. Their LIC602 shows that they require assistance with motor impairment and is non-ambulatory. They require assistance with self-care needs and are unable to manage their own medications. An overall interview with residents expressed that they desired to come out of their rooms. Interview with R1 said that they were told by the owner that they are allowed to come out of their room three times per week, but they have not been out in several days. They would like to be out of their room but need assistance with doing so. R1 also had issues with staff not providing their medications accurately. Interview with resident #2 (R2) preferred to have the ability to leave their bed to the living room. LPA inquired about the number of times they had left the room in the last 5 days, and R2 said that they had not left their room. Since they have been here, they have only left once. Interview with R3 said that they do have a Lyft, but not all the staff know how to use it. They are not often left in their room and would like to go, but the staff are busy. They mentioned that they have sat out in a chair possibly once but would like to go into the living room. Interview with resident #4 (R4) said that the facility at times have a shortage of workers and it takes a toll on them. They are supposed to get out of bed daily but there is no one to help the caregivers. Interview with staff #1 (S1) said that they did not have sufficient time to assist residents with the transfer. An outside source #1 (OS1) did corroborate that they observed resident in their room and R3 has mentioned that staff do not take them out of their room. [Continuation on LIC9099-] [Continuation of LIC9099-C: p.3 of 3] On March 27, 2026, LPA was at the facility and observed that there was insufficient staff to meet the residents' care needs. Residents were interviewed and expressed their desire to be out of their assigned rooms. Throughout LPA’s visit, the residents were not assisted with transferring onto their wheelchairs to come out of their rooms, until about 4:15 PM when one resident was assisted out. During the visit, LPA was left alone for approximately 20 minutes, and during that time, a hospice nurse came, and the staff was out of vicinity not attending with calls or the door when a hospice care staff arrived. LPA was provided a 31 day refusal log - Refusal to sit in chair / Go Outside log. The facility said that they only had this log sheet for resident in room #3 for the month of February 2026. Later LPA reviewed the medications for one resident which were not provided to resident as prescribed by their physician. Numerous medications were missed. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff, resident and outside source interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D page of this report. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Administrator Rose Dorvilus via telephone, and caregiver Myrta Mompremier. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to caregiver Mompremier at the conclusion of the visit. The signature below confirms the receipt of these documents.