Complaint·January 26, 2026

W1 observed two other residents by themselves. W1 then went to Wesley House II, which is next door to the facility and owned by the same licensee, and called for help. W1 states a staff then ran to the facility and assisted R1 in the restroom. During visit on 10/23/2025, LPA Marrufo obtained a copy of R1’s Physician’s Report. R1’s Physician’s Report states R1 requires standby assistance while toileting and R1 can ambulate with assistance. On 11/14/2025, LPA Marrufo conducted a telephone interview with staff S1. S1 stated that around either November or December of 2025, S1 was working a shift at Wesley House II. S1 stated S2 was working a shift at Wesley House III at the same time. S1 stated that at around 2:00 PM, S2 left Wesley House III to go to the bank without notifying S1 that S2 was leaving the facility. S1 stated to have gone to Wesley House III to check if S2 needed help but did not find S2. S1 observed S2 returning to Wesley House III. Then, S1 returned to Wesley House II. S1 also stated that there was another occasion when S2 left Wesley House III to pick up medications and S1 provided supervision to both Wesley House II and Wesley House III alone at the same time for about an hour. On 01/26/2026, LPA Marrufo conducted a telephone interview with S3. S3 stated that there have been times when S3 has been the only staff on duty for both Wesley House II and Wesley House III. S3 stated that the last time S3 had to provide supervision to both facilities alone was around two to three years ago. On 01/26/2026, LPA Marrufo conducted an interview with witness W2. W2 stated to have observed times when there are no staff present at Wesley House III. W2 stated the staff working in Wesley House III will leave the facility unsupervised to help the staff in Wesley House II move a resident who requires two staff. Page 2 of 3. **This report was amended on 02/18/2026 to add "An immediate civil penalty of $500 is being assessed for absence of supervision."** W2 stated to have been present at the facility and to have not observed any sounds of any facility staff at the facility. W2 stated to have later seen S2 in the facility. W2 stated that S2 told W2 that S2 had gone to the pharmacy to pick up medications for S2. W2 stated that he/she told S1 that S2 told W2 that S2 had left the facility to pick up medications for S2. Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. An immediate civil penalty of $500 is being assessed for absence of supervision. This report was reviewed with Hilda Ortiz and a copy of this report and appeal rights were provided. Page 3 of 3. END REPORT