Complaint·January 30, 2026

Facility staff is not meeting resident incontinent needs On 9/25/2025 the Department conduct a complaint investigation visit and interviewed Administrator (ADM), 2 Staff (S1 to S2) and 4 Residents (R2 to R5) and 2 Witnesses (W1 and W2). ADM states residents are checked every 2 hours, as well as being checked at the start of staff shifts, and after residents have finished meals. On 9/25/2025 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 Staff state he/she assists residents with his/her incontinent/toileting needs. On 9/25/2025 the Department interviewed 4 Residents (R2 to R5). 2 Out of 4 Residents state he/she does not require assistance with his/her briefs. R4 and R5 state staff assist him/her with his/her briefs, and staff have never left him/her in a wet brief. On 9/25/2025 the Department interviewed 2 Witnesses (W1 to W2). W1 states he/she observed R1 ‘soaking wet’ but did not remember the date of this incident. W1 states he/she did not observe R1 wet, it was RP, and the RP ‘screamed and yelled’ and ‘got it taken care of.’ W1 did not provide additional information regarding this incident. W2 states he/she has no issues or concerns with the care his/her loved one is receiving at the facility. Review of R1’s physician’s report dated 8/5/2025 notes R1 is not incontinent of bladder. Review of R1’s care plan notes R1 to require toileting assistance (3x daily), and Bladder incontinence assistance (0x – As needed). Staff are not assisting resident with dressing On 9/25/2025 the Department interviewed Reporting Party (RP). RP states he/she observed R1 in briefs on 9/10/2025 at approximately 10:00PM and told staff R1 needed to be wearing pajamas ‘to go to bed.’ RP states this is a ‘general preference and it’s not part of R1’s care plan.” On 9/25/2025 the Department interviewed ADM. ADM states staff assist residents with getting dressed. Page 2 of 5 On 9/25/2025 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 Staff state he/she assists residents in getting dressed. On 9/25/2025 the Department interviewed 4 Residents (R2 to R5). 4 Out of 4 Residents states he/she does not need assistance with getting dressed. R4 states staff offer to help him/her get dressed, but he/she prefers to get dressed on his/her own. On 9/25/2025 the Department interviewed 2 Witnesses (W1 to W2). W1 did not provide additional information. W2 states he/she has no concerns with the care his/her loved one is receiving at the facility. Review of R1’s care plan notes for dressing assistance “2x daily at 6:00AM and 2:00PM.” Facility staff did not provide resident with assistance eating. On 9/24/2025 the Department interviewed Reporting Party (RP). RP states he/she did not observe and does not have any additional information regarding if facility staff did provide R1 with assistance eating. On 9/25/2025 the Department interviewed ADM. ADM states staff assists residents with eating if residents need it. ADM states staff ask residents if he/she need help, or if a resident is not eating his/her food, staff will assist residents with eating. On 9/25/2025 the Department interviewed 2 Staff (S1 to S2). 2 Out of 2 Staff state he/she provides residents with eating assistance. On 9/25/2025 the Department interviewed 4 Residents (R2 to R5). 1 Out 5 Residents state staff help him/her with eating. R3 and R5 state he/she receives their meals on time but did not provide additional information. R4 states ‘maybe once or twice’ he/she was not taken to the dining room but did not provide additional information. On 9/24/2025 the Department interviewed 2 Witnesses (W1 to W2). W1 states a caregiver told him/her that R1 did not receive breakfast on 9/9/2025. Page 3 of 5 W1 states he/she doesn’t know if R1 received breakfast on 9/9/2025. W2 states he/she has no concerns with the care his/her loved one is receiving at the facility. Review of R1’s physician’s report dated 8/5/2025 notes R1 is not able to feed his/herself. Review of R1’s care plan dated 8/19/2025 notes no assistance with eating is noted as part of R1’s care plan. Staff did not dispense medication to resident as prescribed. On 9/24/2025 the Department interviewed Reporting Party (RP). RP states he/she did not observe and does have any additional information regarding if R1’s medications had been given as prescribed. On 9/25/2025 the Department interviewed 2 Staff (S1 to S2). 1 Out of 2 Staff state he/she give residents his/her medications as prescribed. S1 states he/she is not a Medtech and does not assist with resident’s medications. On 9/25/2025 the Department interviewed 4 Residents (R2 to R5). 3 Out of 4 Residents state he/she has no issues with his/her medications. R5 states he/she does not get his/her medications as prescribed or on time. R5 did not provide additional information regarding this incident. On 9/24/ 2025 the Department interviewed 2 Witnesses (W1 to W2). W1 states facility staff did not give R1’s medications because he/she ‘never saw a caregiver give R1 medications during evening and dinner times.” W1 states he/she visited R1 during the evening hours and did not see staff giving R1 medications. R1 states there were three medications (M1, M2, M3) not being given to R1. W2 states he/she has no concerns with the care his/her loved one is receiving at the facility. Review of R1’s Medication Administration Record (MAR) notes M1 and M2 were administered to R1 on 9/10/2025 to 9/14/2025. M3 was not listed on the R1’s list of medications prescribed by his/her physician. M3 was not listed on R1's Centrally Stored Medication and Destruction Record (CSMDR). Page 4 of 5 This agency has investigated the complaint alleging facility staff is not meeting resident incontinent needs, staff are not assisting resident with dressing, facility staff did not provide resident with assistance eating, staff did not dispense medication to resident as prescribed. We have found that the complaint was UNFOUNDED , meaning that the allegations were false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with ADM and a signed copy of this report was provided. Page 5 of 5 END OF REPORT