complaint·October 3, 2025

During interview on 01/19/2023, R1 stated that S1 and S2 speak to R1 in an inappropriate manner by verbalizing disrespectful things to him/her such as saying R1 has “cow shit” or “pig shit” when they assist R1 with changing undergarments. R1 stated S1 and S2 say they don’t like R1 and say they will retire because of R1. During interview on 01/19/2023, S1 and S2 stated to have not spoken to R1 inappropriately. ADM stated during interview that staff do not speak to residents inappropriately. During interview on 09/24/2025, ADM stated that ADM and the staff knew that R1 had complained about R1’s previous care giver, so ADM and the staff did not want to risk talking to R1 inappropriately. On 01/19/2023, the Department obtained copies of R1’s Physician’s Report dated 07/27/2021 and R1’s Appraisal/Needs and Services Plan dated 10/20/2021. Allegation: Staff leaves resident soiled for extended periods of time. R1’s Physician’s Report states R1 had bowel impairment and bladder impairment, R1 was dependent on all his/her Activities of Daily Living (ADLs), and was unable to transfer independently to and from bed.R1’s Appraisal/Needs and Services Plan states two staff would provide lifting during transfers and staff would provide full services with R1’s shower and daily dressing. R1’s Appraisal/Needs and Services Plan states R1 was not able to go to the toilet and R1 wears incontinent supplies. The Physical/Health Method of Evaluating Progress section states, “remind [him/her] to relax [his/her] legs while we are changing [his/her] depends.” The Functioning Skills section states R1 has the following needs: “ambulation, showering, dressing, eating, toileting, [and] incontinence.” The Functioning Skills section includes the following objectives: “provide two people lifting with transfers, ensure [he/she] is safe, provide full services with [his/her] shower, provide full services with [his/her] daily dressing, assist with set up, independent with feeding, not able to go to toilet, [he/she] wears incontinent supplies, [he/she] is incontinent for both urine and bowel.” During interview on 01/19/2023, R1 stated staff S1 and S2 do not take R1 to the bathroom and only change R1’s diaper twice per day. R1 stated staff change R1 at 8:00 AM and 5:00 PM. R1 stated to have no way to notify staff if R1 needs help. R1 stated to not have a bell or the phone number of the staff. R1 stated that he/she text messages the “director of the program.” Page 2 of 5. On 04/01/2025, the Department obtained screenshots of text messages from ADM that ADM stated were between ADM and R1. The text messages include a text from R1 requesting ADM to have staff provide R1 with a ride to the hospital on 10/02/2022. During interview on 01/19/2023, S1 stated staff changed R1’s diapers twice a day. S1 stated if R1’s diapers were wet at lunch time, R1 would verbally call to the staff for help. S1 stated R1 would call for help once per day. S1 stated staff would check on R1 in the afternoon. During interview on 01/19/2023, S2 stated staff check on bedridden residents every two hours. S2 stated if the bedridden residents are wet, the staff will change them. S2 stated staff would check on R1, but R1 does not like to be moved. S2 stated R1 will say he/she is not wet, but he/she would be wet. S2 stated that staff would tell R1 to call for staff to help when he/she is wet. During interview on 01/19/2023, ADM stated that if a resident is unable to go to the bathroom, staff will help residents with toileting at least three to four times a day or as needed. ADM stated at nighttime, staff will place a liner on the bed and there will be a nighttime change. ADM stated staff check on R1 after every meal. ADM stated that S2 asked ADM what to do if R1 refused a toileting needs check, and ADM told S2 to ask R1 again later. During interview on 09/24/2025, ADM stated nighttime staff would provide R1 with a diaper change as needed. ADM stated if R1 refused diaper changes, then ADM would try to convince R1 and talk to R1’s social worker. ADM stated if R1 continued to refuse diaper changes, then ADM and the staff would not force R1 to change diapers. ADM stated R1 would sometimes refuse diaper changes and always refused to be showered. ADM stated staff would need to sponge bathe R1 because R1 refused to shower. Allegation: Facility does not have proper equipment to assist resident in care. During interview on 01/19/2023, R1 stated that R1 needs a Hoyer lift. R1 stated R1’s Physical Therapist told R1 that he/she needs a Hoyer lift. Page 3 of 5. During interview on 01/19/2023, S2 stated that R1’s Physical Therapist said R1 needs a Hoyer lift to transfer R1 to his/her wheelchair and give R1 a shower. S2 stated to not know what happened to the Physical Therapist’s request. During interview on 01/19/2023, ADM stated R1’s Physical Therapist never gave the facility any suggestion about transfer equipment. During interview on 09/24/2025, ADM stated R1 did not want to be transferred from bed. ADM stated R1’s physical therapist never gave ADM any documentation about a Hoyer lift for R1. ADM stated R1 would never give ADM any documentation from R1’s physical therapist or occupational therapist. ADM stated to not be able to remember if ADM had a conversation with R1’s physical therapist about getting a Hoyer lift for R1. Allegation: Staff do not properly store resident's food. When the department received the complaint, it was alleged that the facility staff do not put R1’s food that requires refrigeration in the facility refrigerator, causing the food to spoil. During interview on 01/19/2023, R1 stated R1 orders food from Walmart. R1 stated staff keep R1’s food that requires refrigeration in the refrigerator. During interview on 01/19/2023, S2 stated some of R1’s personal food is stored in R1’s room and some is stored in the facility refrigerator. S2 stated R1 currently does not have any of R1’s own food. S2 stated R1 already consumed R1’s own food. During interview on 09/24/2025, ADM stated R1’s food that needed refrigeration was kept in the facility refrigerator and the rest of the food was kept in R1’s room. Allegation: Staff does not treat resident with dignity or respect. Page 4 of 5. When the department received the complaint, it was alleged that staff were not allowing R1 to put personal items on R1’s desk. During interview on 01/19/2023, R1 stated to have personal items such as a Bible, journal, and crossword puzzles. R1 stated the staff put R1’s items away in a box on the drawer by R1’s bed. R1 stated other objects are covering the box. R1 stated the box with R1’s personal items are out of reach to R1. During interview on 01/19/2023, S1 stated staff give R1 his/her crossword puzzles whenever R1 asks for them. S1 stated staff assist R1 with his/her personal belongings whenever he/she asks. During interview on 01/19/2023, S2 stated R1 has a laptop, an iPad, a Bible, and coloring books. S2 stated R1 does not use his/her belongings and watches television instead. S2 stated R1’s belongings began to pile up on R1’s table. S2 stated S2 put the belongings R1 was not using in a box. During interview on 01/19/2023, R1 stated staff “rip” R1’s legs open when changing R1. R1 stated the way staff change R1 is demeaning and condescending. During interviews on 09/24/2025, S1 and S2 stated to never open R1’s legs in a disrespectful way when cleaning R1 and changing R1’s diapers. During interview on 09/24/2025, ADM stated to not know where R1 is currently located. ADM stated R1 did not provide the contact information for R1’s physical therapist. ADM stated R1’s physical therapist would either call the house phone or speak with R1 directly. ADM stated R1’s physical therapist did not contact ADM on ADM’s cell phone. ADM stated that when R1 was a resident at the facility, the only staff were S1 and S2. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Becky Bi and a copy of this report was provided. Page 5 of 5. END REPORT. During interview 01/19/2023, ADM stated staff use a pot of warm water and a towel to clean up R1. ADM stated staff use non-rinse shampoo in R1’s hair. ADM stated when R1 had leg braces after surgery, staff could not shower R1. During interview on 09/24/2025, S1 stated to have never told R1 that it is not S1’s job to help R1 into the shower seat and shower. S1 stated to have never observed another staff say that helping R1 into the shower is not their job. S1 stated R1 did not like to be moved. S1 stated R1 would refuse to be changed if R1 was in pain. S1 stated if R1 were in pain but very wet, then R1 would not refuse to be changed. S1 stated if R1 refused to be changed, then S1 would return to R1 later to ask to change R1 again. During interview on 09/24/2025, S2 stated to have not stated that it was not S2’s job to help R1 into the shower seat and into the shower. S2 stated S1 would offer R1 a shower, but R1 would refuse. S2 stated to have never observed another staff tell R1 that it was not their job to help R1 into the shower seat and into the shower. S2 stated R1 would refuse to be changed if R1 was in pain. S2 stated staff would return later to ask R1 again to be changed if R1 previously refused to be changed. During interview on 09/24/2025, ADM stated that R1 would schedule his/her own doctor and hospital appointments and keep the hospital discharge documentation. ADM stated to not have any documentation on R1’s hospital visits, because R1 kept the documentation for those visits. ADM stated there was no shower log maintained for R1. During interview on 09/24/2025, ADM stated the only part of R1’s care plan that changed after R1’s surgery was the staff needed to be careful about R1’s knee braces. ADM stated that even before R1’s surgery, R1 was in bed for toileting. ADM stated R1 did not like to shower because it was too painful for R1’s legs. LPA Marrufo conducted a telephone interview with witness W1 on 10/03/2025. W1 stated to have not been made aware by R1 or the facility staff that the staff were cleaning R1 with a pot of warm water, drying R1 with a towel, and cleaning R1’s hair with non-rinse shampoo after R1 had tendon surgery. Page 2 of 3. This agency has investigated the complaint allegations listed. Based on interviews and review of records, the CCLD has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Becky Bi and a copy of this report was provided. page 3 of 3. END REPORT