complaint·December 30, 2025

The Community Care Licensing Department (CCLD) Infection Control Practices References Guide for RCFE states on page 9: “Facilities with COVID-19 cases retest all staff and residents in accordance with Community Care Licensing guidance, until no new cases are identified in two sequential rounds of testing.” On 06/10/2024, the facility submitted an Incident Report stating that on 06/07/2024, resident R1 was found to have an elevated temperature and was transported to the hospital. At the hospital, R1 tested positive for COVID. R1 was returned to the facility on 06/08/2024. During interview on 09/12/2024, LPA Marrufo interviewed Administrator (ADM) Engracia “Grace” Sandoval. ADM stated that after R1 returned to the facility, R1 was isolated in his/her living unit. R2 was the only other resident at the facility at the time. ADM stated that R2 did not need to be isolated since R2 was the only other resident in the facility besides R1 and R1 was being isolated in his/her living unit. ADM stated that the facility did not have COVID tests available when R1 was tested positive with COVID. ADM stated to have ordered more COVID tests and requested COVID tests from other facilities operated by the licensee. ADM stated staff S2 brought a COVID test from S1’s home and used it to test R2. ADM stated R2 took the COVID test and tested positive. ADM stated to have not sent an Unusual Incident/Injury Report for R2’s positive COVID case. During interview on 09/12/2024, S1 stated to have not gotten COVID while working at the facility. S1 stated to have either had a cold or allergies. S1 stated to have had symptoms of coughing and a runny nose. S1 stated to have taken a COVID test at home, and it had a negative test result. S1 stated to have worn gloves and a mask while coughing and having runny nose symptoms. On 12/10/2025, LPA Marrufo obtained a copy of a police report from local law enforcement. The police report stated that a police officer visited the facility on 06/14/2025. During the visit, the police officer conducted a welfare check on R1 and R2. The police officer observed appropriate protective personal equipment for COVID-19 outside of the apartments of R1 and R2. On 12/24/2025, LPA Marrufo reviewed the facility file and did not find an LIC808 COVID-19 Mitigation Plan Report. Page 2 of 4. Allegation: Facility staff do not ensure food is of good quality for residents in care When the department received the complaint, it was alleged that the food is of poor quality and the meat is tough and difficult for the residents to swallow. During visit on 06/20/2024, LPA observed lunch being served to residents R1 and R2. LPA observed a staff cut R1’s chicken into small pieces. LPA observed R2 was served chicken and was given a fork and butter knife. LPA observed R2 cutting the chicken with the fork and by using R2’s fingers. LPA observed that R1 had a staff sitting nearby assisting R1 with eating. LPA did not interview R1 out of concern of causing a choking incident while R1 was eating. During visit on 09/12/2024, LPA Marrufo approached R1 and asked R1 for an interview, and R1 verbally refused to be interviewed. LPA interviewed R2 while R2 was eating lunch. R2 stated R2 can cut the chicken and the chicken tasted fine. R2 stated the food at the facility tastes fair. R2 stated R2 can cut the food and the food is not too tough. R2 stated that R2 can swallow the food. During interview on 06/20/2024, ADM stated that food can be pre-cut for residents and sauces are added to make sure the food is not too dry. ADM stated food is cooked tender enough for residents and the facility has the equipment to ensure the food is tender. Allegation: Staff neglect residents. When the department received the complaint, it was alleged that R2 asked S2 for assistance and S2 stated S2 needed to get coffee first. R2 stated during interview to have never asked for help and not received help from staff. R2 stated to not recall any time when R2 asked a staff for help and the staff stated to need to get coffee first before helping R2. Page 3 of 4. During interview on 06/20/2024, staff S2 stated to have approached R2 while R2 was having breakfast and asked R2 how R2 was doing. S1 stated to have told R2 that S2 cannot function without getting coffee first, but R1 was not asking for help from S2. Allegation: Staff are forcing residents to participate in activities. When the department received the complaint, it was alleged that staff S2 has forced R1 and R2 to participate in activities. During interview on 06/20/2024, S2 stated to have never forced R1 or R2 to participate in activities. During interview on 06/20/2025, R2 stated to have never been forced to participate in activities. During visit on 09/12/2024, LPA Marrufo attempted to interview R1, but R1 refused to be interviewed. Based on information from interviews conducted with staff and residents, 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 Administrator MJ Jain and a copy of this report was provided. Page 4 of 4. END REPORT