Complaint·July 22, 2025

Page 2 of 4. Facility staff do not treat residents with dignity and respect. It was alleged that the facility staff are rude to the residents. On 5/16/2025, the Department interviewed one staff (S1). S1 stated he/she has not seen or heard staff being rude to residents. S1 stated he/she has not heard from other staff that staff are being rude to residents. On 7/3/2025, LPA Rai observed the memory care unit residents and staff for approximately 2 hours. LPA Rai observed staff treating residents with dignity and respect, such as addressing the residents with their preferred names, engaging them in the activity or asking for their permission when moving them to the different areas of the common room. On 7/3/2025, the Department interviewed four staff (S2-S5). Four out of four staff have not seen or heard staff being rude to residents. Three out of four staff stated he/she has not heard from other staff that staff are rude to residents. S5 stated he/she has seen a staff yell at the resident but was not able to remember if the resident was hard of hearing and why the staff was yelling at the resident. On 7/3/2025, the Department attempted to interview five residents but were not able to conduct interviews due to resident refusing to answer questions pertaining to this investigation. Facility staff are not providing adequate food service to residents. It was alleged that the facility staff will clear out resident’s plate when they are not finishing eating. On 5/16/2025, the Department interviewed one staff (S1). S1 stated the facility provides 3 meals and snacks to the residents every day. S1 stated he/she has seen servers provide meals and snacks to the residents in memory care. S1 has not seen/heard staff remove resident’s plates from residents while they were consuming the food. Page 3 of 4. On 7/3/2025, LPA Rai observed the memory care unit residents and staff for approximately 2 hours during lunch service. LPA Rai observed staff waiting for resident to finish their meals before removing the plate, cup or silverware from in front of the resident. LPA Rai observed 2 staff members assisted residents with their meals by cutting their food or feeding them the meal. On 7/3/2025, the Department interviewed four staff. Three out of four staff stated the staff will wait until the resident indicates when they are done with their meal to remove the resident’s plate. S2 stated there is one resident who requires supervision during mealtimes, but staff will assist other residents if they are not able to consume their meals themselves. S5 stated that sometimes the staff will take the plate front in front of the resident, but was not able to remember to recall the name of the staff removing the plates or the name of the resident whose plate was being taken prior to finishing their meal. On 7/3/2025, the Department attempted to interview five residents but were not able to conduct interviews due to resident refusing to answer questions pertaining to this investigation. Facility staff are not adequately supervising residents who may be a fall risk. It was alleged that the facility staff did not observe R1 on 4/25/2025 who had a fall. On 5/6/2025, Reporting Party (RP) stated there were a lot of staff observing resident during the incident including residents and staff. On 5/16/2025, the Department interviewed one staff (S1). S1 stated he/she has not seen or heard staff not supervising fall risk residents. S1 stated residents may fall in the common areas but staff are always present with the residents. On 7/3/2025, LPA Rai observed the memory care unit residents and staff for approximately 2 hours. LPA Rai observed at least 2 residents in the common areas with the residents. Page 4 of 4. On 7/3/2025, the Department interviewed four staff. Four out of four staff were not present during the incident. S3 stated the incident occurred during the shift change at 2pm. S3 stated he/she heard from another staff who stated there were no staff present to observe R1 when the incident occurred. S3 is not able to provide the name of the staff who made the comment to S3. S2 stated there was a staff member present during the incident and it is documents on R1’s progress note dated 4/25/2025. On 7/3/2025, the Department attempted to interview five residents but were not able to conduct interviews due to resident refusing to answer questions pertaining to this investigation. Based on review of LIC 625, Unusual Incident/Injury Report dated 4/25/2025 for R1, R1 was walking with the walker when tripping over another resident’s feet. Based on review of R1’s progress note dated 4/25/2025, staff S1 was present at the time of the incident and resident was assessed after incident and staff called “9-1-1” to seek medical attention. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.