complaint·October 30, 2025

Continued from LIC9099... Interview with Administrator indicated that facility does provide residents with toilet paper but does not provide soap unless responsible parties are unable to. Interview with Administrator indicated that upon loss of an apartment key, a work order is submitted and will be filled within twenty-four (24) hours. Review of R1 care notes indicated that apartment key was lost for at least five (5) days with the first entry of a lost key stating “door key has been gone for a while”. Care notes document staff explaining to R1 that key will be replaced soon, but no entry regarding replaced key was made following the last entry mentioning the lost key on the fifth (5th) day. Care notes indicated that staff would lock apartment door for R1 but R1 was not satisfied by this. Staff did not return authorized representatives calls – RP alleges that facility did not return phone calls to authorized representative in a timely manner after an incident involving R1. Interview with RP indicated that it took twelve (12) days for facility to return phone calls requesting updates on the health of R1 following an incident that resulted in physical injury. RP states that several staff members directed RP to other staff members who would not or could not answer questions. Per RP, staff stated there was only one staff member who could provide the answers needed, but did not inform RP that this staff member would be out for an extended period of time. Review of Resident Notes indicated that calls with responsible parties are not noted aside from initial incident reporting. Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Staff did not notice resident's change in condition – RP alleges that staff did not notice change in condition resulting in UTIs and increased weight gain. Interview with RP indicated that R1 gained approximately forty-eight (48) pounds over the course of three (3) years and was diagnosed with two (2) UTIs. Review of weight log indicated that the weight gain did occur. Review of care notes indicated that UTIs were monitored and R1 was sent out to the hospital. Further review of care notes indicated that R1’s health status was being tracked and monitored. Several care note entries did not share unique information and were identical to previous entries over the course of various days. Resident bathroom is not kept sanitary – RP alleges that R1 bathroom is not regularly cleaned resulting in staining and odors. Interview with RP indicated that they observed unhygienic conditions in R1 bathroom on numerous occasions and would inform facility management, but conditions did not change. Interview with Administrator indicated that rooms receive cleaning once a week as well as any other cleaning required by residents. Facility housekeeping does not keep a notes log of services rendered. Review of care notes indicated that staff logged room/bathroom checks for R1 and did not note any odors or staining. Staff are not following residents incontinence plan – RP alleges that staff did not change R1 incontinence pads on a regular basis resulting in UTIs. Reviews of Functional Evaluation and Negotiated Service Plan for R1 indicated that R1 did require incontinence care. Review of care notes did not indicate entries in regard to incontinence plan. Interview with Administrator indicated that incontinence care is only noted for residents on scheduled incontinence plans and is not logged on care notes. Review of R1 Resident Monthly Assignment Report for the month of September 2025 indicated that staff provided assistance to/from bathroom and assisted with incontinence products on regularly scheduled intervals. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated . No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.