Complaint·November 19, 2025

Staff interviewed stated staff often sit next to R2 to calm them down and redirect them. Staff also stated R2 sits at different tables in the facility, but do not put anything near the chair to prevent them from leaving. Staff stated if they see R2 getting agitated and trying to get out of the chair, they know they want to be moved. On 11/18/2025 at approximately 1:38 pm–1:41 pm, LPA observed R2 and R3 in their wheelchairs at a table, with an empty chair next to each of them, obstructing an exit path from the table. LPA observed R2 attempting to stand up from the table. LPA observed two staff standing against the wall away from the table. One staff interviewed indicated the empty chair next to residents with no caregiver does appear like the chair is blocking the residents in. The staff also stated there is typically a staff in the chair next to the residents. Administrator confirmed the residents are not physically able to get up from the table on their own if the chairs are blocking them in. On 11/18/2025, LPA observed R2 and R3 three separate times during the visit sitting in their wheelchairs at the table with the empty chairs next to them, and at no time were the chairs occupied by staff. Administrator stated the chairs are not supposed to be next to the residents when they are empty and when staff are not sitting in them next to the residents during activities. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit. resident to the dining area presentable, with care provided for hair, teeth, clean clothes, with socks and shoes. If a resident refuses, they try again at a another time and let their physician know if the behavior is not normal. Caregivers document if a care task did not get done. One staff noted that although R1 was showered, their hair appeared greasy the next day. Staff interviewed did not recall R1 refusing showers often or not being showered. R1’s visitor was interviewed, who indicated they observed R1’s toiletries including toothpaste, deodorant and face lotion, at the back of a cabinet inaccessible and appearing to not be used. R1’s visitor stated their toothbrush and toothpaste were new and unused for a month, showing R1’s teeth had not been brushed. Staff stated residents’ care needs are indicated in their care plan, and teeth should be brushed twice a day. Staff stated some residents use mouth swabs with mouthwash, which are a sponge on the end of a stick. Staff stated some residents do not like their teeth brushed, but they have a right to refuse and are not forced. Most staff interviewed did not recall R1 refusing care often. One staff stated R1 did not like having their teeth brushed, and on one occasion did not spit out the water for 30 minutes during teeth brushing, despite staff asking them to. R1’s visitor indicated they have found R1 “unkempt” with feces under their fingernails and sitting in wet briefs. Staff interviewed were consistent and stated no residents are in wet briefs for an extended period of time, as the care plan indicates what residents need assistance with and they are regularly checked and changed, or assisted to the toilet. A witness stated on 05/13/2025 at around 3:50 pm, they witnessed a resident in the common area calling for staff multiple times, stating they needed to use the restroom. The witness observed two caregivers engaged in a conversation instead of helping the resident. The witness informed a staff member about the situation, but stated they felt the staff were dismissive. During visits to the facility for the investigation, LPA did not observe any malodors and observed caregivers present around residents in the common areas, attending to residents. One staff stated about a year ago there was one resident who had a behavior of sticking their hand in their brief, and their family member cleaned their nails. There was no other evidence found to suggest residents were sitting in wet briefs or had dirty hands. R1’s visitor also noted they have observed R1 not properly dressed, as they were not wearing a bra or socks, and had their roommate’s pants on that were too small and tight. Staff stated some residents don’t like to wear bras, and med techs are informed if the clothing is too small so that can be communicated to the responsible party. Care staff stated the caregivers know each resident’s clothes and most items are labeled, but occasionally there are mix ups with residents’ laundry put into the wrong room that are corrected. Staff Please continue to 9099-C, Pg 3. interviews did not indicate a resident was dressed in another resident’s clothing. Staff interviewed more recently indicated clothing items are labeled and do not get mixed up, although sometimes residents leave their jackets in the common area and staff return them. R1’s visitor stated R1 was not assisted properly with feeding, such as being fed pieces that were too large or were not finger foods, even though R1 was supposed to receive assistance with feeding. Staff stated if a resident has a special diet, the kitchen is informed and the food prepared accordingly. If there are issues with a resident eating, that information is communicated to the doctor for a change diet order or for additional evaluation. Staff also stated they try to accommodate residents’ preferences. Staff stated they must provide the care services listed on the resident’s care plan. Staff indicated some residents eat with their hands. The investigation did not reveal any evidence that staff did not assist R1 with meals. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. The facility is reminded of their responsibility to provide adequate care and supervision to meet residents’ needs. On the allegation: Staff failed to safeguard residents' personal belongings. It was alleged a resident’s glasses were missing, and staff brought a visitor four different pairs that did not belong to the resident. It was alleged residents may be without their glasses, dentures and hearing aids. It was also alleged another resident takes R1’s personal items such as stuffed animals and toys. R1’s visitor stated staff do not put R1’s glasses on them unless instructed to do so. Staff interviewed indicated they are supposed to make sure hearing aids are turned on during the shift. Staff interviewed stated they did not remember R1 or any other resident losing their glasses or hearing aid. Staff interviewed indicated they have all glasses and hearing aids labeled, and the items are collected at bedtime and kept in the med tech station overnight, unless the family requests to keep the items in the room. R1’s visitor stated staff indicated R1’s roommate likes to put things away, and this accounts for why items go missing. Most staff interviewed did not remember R1’s stuffed animal, but stated there were common area activity items and stuffed animals. One staff stated they remembered R1’s stuffed animal dog was missing at one time but was found after a short amount of time, but they could not recall more details. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. The facility is reminded of their responsibility to safeguard residents’ personal belongings and ensure access to them, and provide adequate supervision to residents. Exit interview conducted and a copy of this report issued at the time of the visit.