Complaint·February 26, 2026

Page 2 of 6. Facility staff handles residents in a rough manner. It was alleged that staff (S1) is often rough with residents when assisting them. On 9/19/2025, the Department interviewed 7 residents (R1-R7). 6 Out of 7 residents stated the staff, including S1, are not rough with them when they assist them. R3 stated staff S1 would push the wheelchair really fast and then suddenly stop causing a jerking movement. R3 stated he/she does not have feelings on the right side of the body, including leg and it’s hard for R3 to determine if S1 is being rough. On 12/18/2025, LPA Rai interviewed 2 staff. 2 Out of 2 staff stated they have not seen or heard of staff S1 being rough with resident when assisting them. S2 stated he/she has seen S1 assist another resident in the bathroom and the resident stated “a man is hurting me” but S1 was lifting the resident which made the resident uncomfortable and it was not rough. LPA Rai interviewed Interim Executive Director, Brenda Ritter, who stated they conducted an internal investigation, and they did not find a preponderance of evidence to prove the allegation. On 02/05/2026, LPA Rai interviewed 7 staff (S4-S10). 7 Out of 7 staff stated they have not seen S1, or any other staff bring rough with residents at the facility. S7 stated he/she worked with S1 during the same shift and did not observe S1 being rough with residents. During this investigation, LPA Rai attempted to reach out to S1 but was unsuccessful. S1 no longer works at the facility. Facility staff do not treat residents with dignity and respect. It was alleged that staff (S1) make fun of resident R3. On 9/19/2025, the Department interviewed 7 residents. 6 Out of 7 residents stated the staff, including S1, treat them with dignity and respect. R3 stated staff S1 did mock him and repeated a word in a sarcastic tone but did not give any other examples or incidents. Page 3 of 6. On 12/18/2025, LPA Rai interviewed 2 staff. 2 Out of 2 stated they have not seen or heard staff S1 making fun of residents. S2 stated R3 has stated that S1 said R3 “was stupid”, but S2 has not seen this interaction. S2 stated R3 has not brought up any other similar incidents in the past. LPA Rai interviewed Interim Executive Director, Brenda Ritter, who stated they conducted an internal investigation, and they did not find a preponderance of evidence to prove the allegation. On 02/05/2026, LPA Rai interviewed 7 staff (S4-S10). 7 Out of 7 staff stated they did not see or hear staff S1 or other staff making fun of resident R3. 4 Out of 7 staff stated that resident R3 would not treat staff with dignity and respect. 4 out of 7 staff stated R3 would be disrespectful towards staff which would include R3 yelling at them. During this investigation, LPA Rai attempted to reach out to S1 but was unsuccessful. S1 no longer works at the facility. Facility staff are not meeting the residents’ incontinent care needs It was alleged that PM staff did not assist resident R1 with PureWick system which caused R1 to be soiled a lot more than usual. On 9/19/2025, the Department interviewed 7 residents (R1-R7) 1 out of 7 residents was confused about their incontinent status. 1 out of 7 residents stated they do not have any incontinent care needs and staff are available to assist as they check on the residents throughout the day. On 9/19/2025, LPA Christine Kabariti observed 7 resident rooms, including R1’s room. 7 Out of 7 resident’s rooms did not have a foul order which would indicate the residents were not changed in a timely manner causing saturation of urine and stool in the resident’s bedding. Page 4 of 6. On 12/18/2025, LPA Rai interviewed 2 staff. 2 Out of 2 staff stated the staff are checking on the resident every 2 hours and using the electronic device to initial on R1’s chart about observing Purewick and if R1 needs assistance with Purewick. Both staff stated they have not seen or heard about R1’s incontinent care needs not being met by the staff. LPA Rai interviewed Interim Executive Director, Brenda Ritter, who stated they conducted an internal investigation, and they did not find a preponderance of evidence to prove the allegation. On 02/05/2026, LPA Rai interviewed 7 staff (S4-S10). 6 Out of 7 staff stated the staff did provide incontinence care to resident R1 and they were meeting R1’s incontinence care needs in regard to the Purewick. S6 stated they worked directly with R1 and has assisted R1 with the Purewick. S7 stated there were 1 or 2 incidents in the past where the Purewick was not placed correctly which caused resident to be soiled but the staff were able to fix the problem right away. Based on review of R1’s Physician’s Report dated 11/13/2024, R1 is incontinent with bladder impairment and is unable to care for their own toileting needs. Based on review of R1’s Service Plan Report dated 7/30/2025, the facility staff are to assist the resident with Purewick at night. Facility staff did not ensure to provide residents with adequate bedding in a timely manner. It was alleged that residents are not provided with bedding (sheets and bed covers) for days. On 9/19/2025, the Department interviewed 7 residents. 2 out of 7 residents did not express concern about having adequate bedding in their room. On 9/19/2025, LPA Christine Kabariti observed 7 resident rooms. 7 Out of 7 resident’s beds had bedsheets and linens. Page 5 of 6. On 12/18/2025, LPA Rai interviewed 2 staff. 2 Out of 2 staff stated residents are responsible to providing their own bedding however, the facility does have extra bedding sheets to use and will provide them to the residents. Neither staff have seen residents without bedding in their rooms. LPA Rai interviewed Interim Executive Director, Brenda Ritter, who stated they conducted an internal investigation, and they did not find a preponderance of evidence to prove the allegation. On 02/05/2026, LPA Rai interviewed 7 staff (S4-S10). 7 Out of 7 staff stated the facility staff do provide residents with adequate bedding. 7 Out of 7 staff stated they have not seen or heard any issues with residents not having bedding in their room. Facility staff do not provide adequate laundry service. It was alleged the staff are not washing resident’s clothing where laundry hampers are overflowing, causing residents to wash their own clothing in their sinks as well as not having clothing to wear. On 9/19/2025, the Department interviewed 7 residents (R1-R7). 5 Out of 7 residents stated the facility staff do provide adequate laundry services. 2 Out of 7 residents could not provide information about the laundry service, but resident stated they have clothes available to wear. On 9/19/2025, LPA Christine Kabariti observed 7 resident rooms. LPA Kabariti observed 6 out of 7 residents’ baskets were full. LPA Kabariti observed that 7 out of 7 residents had more than 5 articles of clothing available such as blouses and pants located in the closet and dresser for resident’s use. On 12/18/2025, LPA Rai interviewed 2 staff. 2 Out of 2 staff stated there is a laundry schedule that the staff will follow and the care staff will do small loads as needed for the residents. Both staff stated they have not seen residents without clean clothes or laundry service was not completed for a resident. LPA Rai interviewed Interim Executive Director, Brenda Ritter, who stated they conducted an internal investigation, and they did not find a preponderance of evidence to prove the allegation. Page 6 of 6. On 02/05/2026, LPA Rai interviewed 7 staff (S4-S10). 7 Out of 7 stated the facility staff do provide adequate laundry services. 3 Out of 7 staff stated there is a resident that has a behavior where he/she will wash their own intimates in the shower however the facility staff will wash the items in the washing machine as well. S7 stated the resident has the behavior and it is not related to the facility staff not providing laundry services. S8 stated the residents may wear their favorite sweater or cardigan multiple times but they have not seen residents wear the same clothes two days in a row. Based on review of resident laundry shift effective 9/8/2025, each resident was assigned a specific date when the laundry would be completed, and each resident was provided laundry service every week. 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 Health and Wellness Director, Baneen Amiri and a copy of the report was provided.