Complaint·April 13, 2026

On 11/4/2025 the Department conducted the initial complaint investigation visit and interviewed 3 Staff (S1 to S3), and 4 Residents (R2 to R5). The Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff stated he/she changes residents with incontinence more frequently than every 2 hours. S3 stated he/she was called to R1’s room for assistance. S3 did not remember the date of this incident. S3 stated he/she was called to R1’s room while he/she was passing medications, and it took him/her approximately 6 minutes to get to R1’s room. S3 stated he/she did not observe R1 to be soiled. The Department interviewed 4 Residents (R2 to R5). 3 Out of 4 Residents stated he/she does not require toileting assistance from staff. R2 stated he/she did not know about staff assisting residents with toileting. On 11/25/2025 the Department 2 additional staff (S4 and S5). S4 stated he/she was not working on 10/20/2025. S5 did not provide additional information regarding this incident. Review of R1’s Physician’s Report dated 2/12/2023 states R1 can manage his/her own toileting needs, incontinence was not indicated/noted for R1. Review of R1’s care plan dated 6/19/2025, R1 does not require assistance with toileting, and self manages his/her incontinence. Staff did not ensure resident had clean bedding The Department interviewed Reporting Party (RP) on 10/31/2025. RP stated he/she observed R1’s bedding to be soiled and needed to be changed on 10/20/2025. RP states at the same time, a staff member came into the room. RP stated he/she thinks the staff was there to change the bedding. RP did not provide additional information. The Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff stated the facility has a laundry schedule, and each resident has a specific laundry day. S2 stated if residents have soiled items (clothing, bedding, etc), he/she will take the soiled items to the laundry for housekeeping to wash. S3 stated he/she was called to R1’s room for assistance on 10/20/2025. Page 2 of 3 S3 stated he/she was passing medications, and it took him/her approximately 6 minutes to get to R1’s room. S3 states he/she did not observe R1's bedding to be soiled. The Department interviewed 4 Residents (R2 to R5). 4 Out of 4 Residents stated his/her bedding is changed/washed by the facility. On 11/25/2025 the Department 2 additional staff (S4 and S5). S4 stated he/she was not working on 10/20/2025. S5 did not provide additional information regarding this incident. Review of R1’s care plan dated 6/19/2025, R1 does not have additional laundry services besides what is included in rent. Per R1’s admission agreement dated 3/16/2022, R1's laundry is scheduled once a week. Staff did not ensure resident's showering needs were being met The Department interviewed Reporting Party (RP) on 10/31/2025. RP stated he/she is not sure if R1 was bathed and did not know R1’s shower schedule. RP stated it ‘appears’ that R1’s hair was 'greasy’ on 10/20/2025. The Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff stated each resident has his/her own shower schedule and staff bathe resident’s according to the shower schedule. On 11/25/2025 the Department interviewed 2 additional staff (S4 and S5). S4 stated he/she was not working on 10/20/2025. S5 did not provide additional information regarding this incident. The Department interviewed 4 Residents (R2 to R5). 3 Out of 4 Residents stated his/her bathing needs are being met. R3 stated he/she does not need assistance with bathing/showering. Review of R1’s care plan dated 6/19/2025, R1’s ‘bathing frequency’ 1-2 times weekly and requires ‘hands-on assistance’ with bathing. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies were cited during today’s visit. An exit interview was conducted with GM, and a copy of this report was provided. Page 3 of 3 END OF REPORT On 11/25/2025 the Department 2 additional staff (S4 and S5). S4 stated he/she was not working on 10/20/2025. S2 statesd he/she did not see any documentation that R1’s physician was notified about R1 not feeling on 10/16/2025 and 10/19/2025. S5 stated R1 was assessed (vitals taken) by a MedTech on 10/16/2025 and 10/19/2025 when R1 stated he/she was not feeling well. S5 stated R1 was assessed at ‘baseline’ by a Medtech on 10/16/2025 and 10/19/2025. S5 states it is the responsibility of the Medtech to inform a resident’s physician about a change in condition. GM states on 10/16/2025, the physician was not notified due to the MedTech assessing R1 and determining R1 to be at ‘baseline.’ Review of R1’s progress notes dated 10/12/2025 to 10/25/2025, notes on 10/16/2025, a progress note category at 2:00PM ‘Alert Charting’ R1 was noted as ‘might be sick’. On 10/19/2025, a progress note category at 5:40AM ‘Change of Condition’ notes R1 to have change in bowel movements. The Department requested documentation of the dates and times when R1’s responsible parties were notified about R1 not feeling well on 10/16/2025 and the change of condition noted on 10/19/2025. The facility was unable to provide documentation that R1’s responsible party and physician had been notified. Review of R1’s emergency room discharge paperwork dated 10/20/2025 to 10/22/2025, R1 was noted with discharge on the eyelids, conjunctivitis was listed as one of the diagnoses. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED . California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted with General Manager (GM) Candace Bolin and a copy of this report was provided. Appeal rights were also provided. Page 2 of 2 END OF REPORT