complaint·March 18, 2025

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. This investigation consisted of a review of documents, site visits to the facility and statements from witnesses and the parties. The following determinations are made: Resident (R1) resides in the facility's memory care unit and shares a room with another Resident (R2); Family members of R1 express concerns that R2 has entered R1's area on many occasions resulting in R1's personal rights being compromised; Facility staff have made hourly wellness checks on R1 in an attempt to prevent R2 from entering R1's area uninvited; Family members have provided videos taken on 2/21/2025 and 3/7/2025 which depict R2 entering the bed of R1 while the bed is occupied by R1 and one depicting R2 entering the bed of R1 which is unoccupied after R2 has removed R2's pants, exposing R2's buttocks. Based upon the videos and statements, there is a preponderance of evidence to prove that the allegation of a personal rights violation has been SUBSTANTIATED and is valid. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Rights provided.