Complaint·July 11, 2025

The facility administrator physically abused a resident while in care. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff stated the facility administrator did not physically abuse a resident while in care. S4 stated on 6/20/2025 he/she saw the facility administrator abuse a resident while in care. S4 stated that he/she filed the report but did not provide any additional information and details of the abuse during the interview. On 7/11/2025, LPA interviewed 3 Residents (R1 to R3). 3 Residents states he/she has not observed facility staff abusing residents in care. The facility is falsifying staff training documents. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff stated the facility is not falsifying staff training documents. S4 stated he/she was asked by the facility administrator to sign training documents for other staff members in 2022. S4 was not able to provide additional information. During review of facility training records, LPA observed that the facility staff signed training documents when training is administered, and certificate is issued based on the staff’s completion of the training required. On 7/11/2025, LPA interviewed 3 Residents (R1 to R3). 3 Residents states staff know what they are doing when providing care to residents. The facility served food that was not in good quality and in quantity necessary to meet the residents' needs. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed S1 to S6. 5 Out of 6 staff state the facility serves food that is of good quality and quantity to meet resident’s nutritional needs. S4 states the facility serves soup, small portions, does not ‘complement’ food with vegetables or rice, and has observed brown spots on lettuce served but did not provide additional information. Page 2 of 5 LPA interviewed 8 Residents (R4 to R11). 8 Out of 8 residents states the facility serves food that is good quality and quantity that meets their dietary needs. On 7/11/2025 LPA interviewed 3 Residents (R1 to R3). 3 Residents states the facility serves food that is good quality and in good quantity. LPA inspected the food pantry, kitchen pantry, refrigerator and freezer. LPA observed refrigerator temperature is maintained at 32-degree F and freezer at 0 degree F. LPA observed 2 days of perishable food that are not expired and are of good quality and quantity, 7 days of non-perishable food that are not expired, no dented cans, no open boxes or exposed food was observed . The facility did not provide hygiene supplies necessary for personal care to residents in care. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff state the facility provides hygiene supplies necessary for personal care to residents. S4 states the facility has no towels or toothpaste for residents but did not provide additional information and details during the interview. On 7/11/2025 LPA interviewed 3 Residents (R1 to R3). 2 out 3 residents state his/her family purchases their hygiene products (toothpaste, shampoo,etc). R3 states the facility provides him/her with hygiene products. LPA inspected the facility bathrooms, living rooms and other high traffic areas. LPA observed trash bins have a cover and are lined with a trash bag. LPA observed the facility bathroom, living room including kitchen and dining surface to be sanitary. LPA observed paper towels, and hand soap used by residents, and staff in the bathroom. LPA observed linen cabinets and observed clean towels for use by residents. Licensee did not ensure the facility had cleaning supplies to maintain cleanliness of facility. Page 3 of 5 On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6).  5 Out of 6 staff state the facility has cleaning products to adhere to the infection control plan by keeping the facility sanitized at all times.  S4 states the facility did not allow staff to use the cleaning products because staff “use too much” but did not provide additional information during the interview. LPA inspected the chemical supply cabinet/room and observed cleaning solutions used by the facility to sanitize resident’s room, bathroom and other areas of the facility. LPA observed that the chemicals are stored in a locked cabinet/room not accessible to residents in care. LPA observed PPE (personal protective equipment) available for use by staff and residents. LPA observed bottles of 1 gallon sanitizing product, bottles of hand sanitizer, vinyl gloves, boxes of face mask, laundry detergents and hand soaps, toilet paper, and paper towels in bulk quantity. LPA reviewed facility grocery receipts with a date range from 12/17/2024 to 1/7/2025, documenting 7 grocery purchases to include but not limited to food supply both perishable and non-perishable food. Grocery receipts show purchases of vinyl gloves, personal care wipes and cleaning products, necessary for use in cleaning, disinfecting and sanitizing the facility surfaces and other areas of the facility in compliance with California Code of Regulations (CCR) Title 22, 87470 Infection Control Requirements. The facility is not reporting medication errors to the Department. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff state he/she has not observed medication errors not being reported to the Department. S4 states residents have been given other residents medication, but did not provide additional information during the interview. LPA reviewed the facility file record and observed no incident reports for medication errors. Based on review of records, LPA did not observe any medication error during the document review of resident’s records from December of 2024 to January of 2025. The facility staff are not trained to provide the services necessary to meet resident needs. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff stated they have received training to meet residents’ needs. S4 stated he/she was asked by the facility administrator to sign training documents when no training was received. S4 was not able to provide additional information. Page 4 of 5 **Amended on 8/8/2025 to change findings from unfounded to unsubstantiated** During the annual inspection conducted on 03/27/2025, a review of 5 staff records was conducted. 5 Out of 5 staff records contained proof of current training for 2025, that adheres to the regulation requirement under the California Code of Regulations (CCR) Title 22, 87411 Personnel Requirements and under Health and Safety Code 1569.625 and 1569.69. On 7/11/2025 LPA interviewed 3 Residents. 3 residents states facility staff know what they are doing when providing care. The facility does not maintain a comfortable temperature for residents. On 1/8/2025, 5/12/2025 and 5/13/2025, LPAs interviewed 6 staff (S1-S6). 5 Out of 6 staff stated the facility maintains a comfortable temperature for residents. S4 stated the facility is ‘very cold and had to wear long sleeves.’ S4 did not provide additional information. On 1/8/2025, LPA inspected and observed 11 resident rooms on the first and second floor. The facility has a thermostat to measure room temperature. Thermostat was observed to be set at 72 degrees F to 80 degrees F. LPA observed that the facility maintained the temperature in compliance with California Code of Regulations (CCR) Title 22, 87303 Maintenance and Operation by maintaining a comfortable temperature for residents at all times. On 7/11/2025 LPA observed the 2 facility thermostat temperatures on the first floor at 73 and 75 degrees F. LPA observed the facility thermostat on the second floor at 74 degrees F. LPA interviewed 3 Residents. 1 out 3 residents states he/she has no concerns with facility temperature. 2 residents were having lunch and unable to be interviewed. Although the allegations 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 allegations are UNSUBSTANTIATED . An exit interview was conducted, and a copy of this report was provided. No deficiencies cited during today’s visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with the Manager Betzy Torres and a copy of this report was provided. Page 5 of 5.