complaint·June 4, 2025

W1 stated that W3 is not part of a care team and screamed at the staff who just checked on R1. W1 stated that W3 was angrily screaming at staff who just cared for R1 and stated that R1 was not being cared for properly. W2 cannot be contacted. W3 stated that he/she did not see the compromised skin of R1 and does not know R1s care plan. W3 stated that he/she had a feeling that nothing was done, no photos were taken. W3 stated that a Home Health Care comes to the facility to care for R1 three times a week. W3 stated family and himself/herself visited R1 and stated R1s hair was washed and bed was ‘spic and span’. On 5/23/2025 LPA Tarin interviewed W4. W4 stated he/she provided care for R1, assisted with feeding when R1 requests for assistance. On 4/4/2025, 4/24/2025 and 5/14/2025, LPAs interviewed 11 staff (S1-S11) and 10 residents (R1-R10). Based on interviews, 7 out of 11 staff (S1-S11) stated staff provides feeding assistance to residents. 4 out of 11 staff stated they work the nocturnal shift, and meals are not provided during this time. Based on interviews 10 out of 10 (R1-R10) residents stated they do not need assistance from staff with feeding. Staff allowed resident to be left in soiled clothing for extended periods of time Based on interviews, 7 out of 11 staff (S1-S11) stated they did not observe a resident left in soiled clothing for extended periods of times. 3 out of 11 staff stated they observed a resident left in soiled clothing. 1 out of 11 staff did not provide any information. Based on interviews, 10 out of 10 residents (R1-R10) stated they have not observed a resident left in soiled clothing for extended period of time. On 5/23/2025 LPA Tarin interviewed W4. W4 stated he/she did not observe R1 in soiled clothing for extended period of time. Staff did not reposition resident Page 2 of 3 Based on interviews, 10 out of 11 staff (S1-S11) stated they reposition residents based on their care plan. 1 Out of 11 staff did not provide any information. Based on interviews, 10 out of 10 residents (R1-R10) stated he/she does not need repositioning. On 5/23/2025, LPA Tarin interviewed W4. W4 stated he/she repositioned R1. W4 stated there were occasions when R1 did not allow him/her to be repositioned. W4 could not provide exact dates when R1 refused to be repositioned. Based on document review of resident care plans, 1 out of 4 residents were under hospice care. 1 out of 4 residents were diagnosed with a terminal illness and major neurocognitive disorder. 3 out of 4 residents do not require feeding assistance based on the care plan. 1 out of 3 residents care plan stated that residents in hospice care are repositioned, checked and cleaned every 2 hours. Based on interviews, document reviews and observations, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegations are unsubstantiated. No deficiencies were cited during today’s visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director (ED) Alex Baiasu via phone and authorized S1 to sign on his behalf. A copy of the report was provided .