Complaint·March 24, 2026

During interview on 08/26/2025, a department investigator interviewed S2. S2 stated that while S2 was walking past R1 in the common area, S2 noticed that R1 looked disoriented and was not looking at his/her personal companion while his/her personal companion was talking to him/her. S2 observed R1 in the dining room area. S2 observed R1 to be slouched to his/her side, not eating, and not taking his/her medication. S2 stated R1’s face did not appear to be drooping. S2 stated to have told S3 about R1’s change in condition. During interview with a department investigator on 08/26/2025, S3 stated that on 03/04/2025 at around 8:30 AM, R1 was brought to the dining room table for breakfast and medications. S3 stated that S2 asked S3 to check on R1. S3 used the whiteboard to ask R1 if R1 was okay, and R1 nodded his/her head to indicate he/she was okay. S3 used the whiteboard to ask R1 if he/she was in pain or if he/she needed an ambulance, and R1 responded no. There were no physical assessments like range of motion, skin checks, or alertness that were completed at that time. S3 called R1’s family member FM1 to ask FM1 if R1’s behavior was normal. FM1 stated to not know if R1’s behavior was normal, so FM1 asked S3 to have staff monitor R1 and wait until R1’s other family member, FM2, could arrive at the facility and assess R1. S3 continued to monitor R1 from 8:30 AM to 12:30 PM, when emergency response personnel arrived. S3 stated that R1 was still able to answer yes or no questions until emergency response personnel arrived. Allegation: Staff did not seek emergency medical care for resident On 03/04/2025, at about 7:30 AM, staff S2 reported that he/she thought resident R1 appeared “off” to S3. S3 was unsure if R1 was at baseline, so he/she communicated to R1’s Family Member, FM1. FM1 was unsure if R1 was at baseline because R1 had a history of irregular mood changes. FM1 advised staff to wait for R1’s other family member, FM2, to assess R1 so they could decide whether to call 911. From 8:30 AM to 12:30 PM, S3 monitored R1 until FM2 arrived at the facility. Upon FM2’s assessment, FM2 directed staff to call 911. S3 called 911 at 12:30 PM. Page 2 of 3. Prior to FM2’s arrival, R1 did not report to be in pain nor did S3 observe R1 to exhibit life-threatening symptoms. S3 stated during interview that if R1 had become non-responsive or showed obvious signs of decline, he/she would have bypassed FM1’s instructions and called 911. At the hospital, R1 was determined to have had a mild stroke. R1’s medical records corroborate that R1’s stroke may not have been obvious at the time of the incident. Based on information from interviews conducted with staff, 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 Jackie Colores, staff, and a copy of this report was provided. Page 3 of 3. END REPORT This agency has investigated the complaint allegations listed. Based on interviews, review of records, the CCLD has found that the complaint allegations are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Jackie Colores, staff, and a copy of this report provided. Page 2 of 2. END REPORT