complaint·June 9, 2025

LPA investigated the allegation, “Staff do not treat residents with dignity and respect.” Based on interviews conducted it was indicated that multiple staff would tell R1 they would use the hoyer lift to get R1 out of bed, knowingly R1 is afraid of the lift. Interviews revealed staff suggest the use of the hoyer lift as a motivational tool to get R1 out of bed. Interviews indicated that staff would yell at R1 when he did not want to get out of bed in the mornings, which negatively impacts resident's sense of well-being. LPA investigated the allegation, “Staff are not providing residents with adequate hand washing supplies.” During visit conducted on April 8, 2025, LPA observed two of two facility bathrooms did not have paper towels and soap. Staff stated they would provide paper towels for both bathrooms during LPA’s inspection. Additionally, during visit conducted on April 17, 2025, LPA observed both bathrooms still did not have paper towels. As a result of LPA’s visits on April 8, 2025, and April 17, 2025, LPA determined that the facility was not providing adequate hand washing supplies. Interviews also indicated the facility had been running out of hand soap on multiple occasions. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D. An exit interview was conducted, and a copy of the report and appeal rights were provided. LPA investigated the allegation, “Staff do not maintain resident areas clean and orderly.” Based on interviews and observations, LPA observed that the facility was relatively clean and organized. LPA toured resident rooms which also appeared to be clean and orderly. No interviews revealed that the facility is kept unsanitary or that cleaning duties are neglected. Staff stated that, at times, they become busy or are behind schedule, but that they work together to accomplish cleaning tasks. LPA investigated the allegation, “Staff do not seek timely medical attention for residents.” Based on interviews conducted that medical assistance had been sought out when facility staff found out about R1’s sores. Interviews indicated that facility policy is that when it is determined a resident needs emergency medical attention, the facility initiates emergency services. Staff made appointments to address R1’s sores. The Department was unable to determine through interviews and documentation if the facility failed to seek timely medical attention for R1. LPA investigated the allegation, “Licensee does not ensure enough staff to meet residents needs.” Based on interviews and observations, evidence was not found to support that there were insufficient staff to meet the needs of resident identified care needs. Interviews indicated there are usually two staff working on each shift. LPA observed during multiple visits two staff members working at the facility during the time of the investigation. LPA investigated the allegation, “Staff are not meeting resident bathing needs.” Based on interviews conducted, staff indicated that residents receive sufficient care with bathing, grooming, and hygiene. Staff interviews revealed that residents receive showers unless they refuse. If a resident refuses the staff will make several attempts to see if they want to shower. Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. Findings that the complaint is Unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.