complaint·February 23, 2026

Continued from LIC9099... Interviews with two (2) out of nine (9) staff indicated that hand-over-hand injections are used. Interviews with three (3) out of nine (9) staff indicated that many Assisted Living residents are not capable of or will refuse to follow hand-over-hand procedures. Review of in-service training logs dated 12/4/25 and 12/25/25 indicated that training on hand-over-hand injections has since been given. Interviews with three (3) out of nine (9) staff in dicated they were not aware any trainings have been held or were told to sign the in-service log without attending the training. Based upon evidence gathered, 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 Assistant Executive Director , whose signature on form confirms receipt. Continued from LIC9099A... Interview with one (1) out of five (5) residents indicated that there is an ongoing issue with low staffing due to callouts without backup. Interviews with four (4) out of five (5) residents indicated that staff are friendly and helpful with enough staff to provide assistance and care. Staff did not follow resident’s prescribed medication orders – Reporting Party (RP) alleges that staff do not administer medication to residents at their prescribed times. Interview with three (3) of eight (8) staff indicated that there is a lack of medcarts in the facility leading to too many residents being assigned to each individual cart, making it difficult to deliver medications on time. Interview with one (1) of eight (8) staff indicated that residents have reported hearing management rush staff over walkie-talkies during medication passes leading to resident anxiety. Interviews with three (3) of five (5) residents indicated that they receive their medications on time and have not experienced delays. Interview with one (1) of five (5) residents indicated that they will occasionally have to request their medication be given. Interview with one (1) of five (5) residents indicated that they did not receive their breakfast medication until lunch. Reviews of ten (10) Assisted Living and ten (10) Memory Care Medication Administration Records (MARs) indicated that medication is being logged as administered per prescribed orders. Resident refusals are logged onto the Note page as well faxes to physicians. Facility is not following infection control procedures – Reporting Party (RP) alleges that residents with communicable or infections disease are being retained without use of proper infection control. Interviews with two (2) of eight (8) staff indicated that there have been numerous instances of residents being diagnosed with Clostridium Difficile (C.diff) and Methicillin-resistant Staphylococcus Aureus (MRSA) being retained in the facility. During this investigation, LPA was made aware that a resident (R1) was currently diagnosed and residing in the facility with a diagnosis of MRSA. LPA observed cabinets containing PPE outside of R1’s room for staff use. Interviews with five (5) of eight (8) staff indicated that they were not aware of R1s exact diagnosis, however, they were donning PPE as a whiteboard in the staff room stated R1 had an infectious skin disease. Review of Incident Report received by Community Care Licensing on 2/4/2026 indicated resident was diagnosed on 1/31/2026 and the facility requested an exception to retain a resident with a restricted health condition on 2/4/2026. Review of in-service documents indicated that a training was held on 1/30/2026 on providing care to MRSA positive residents. Although the allegations 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 cited. Exit interview conducted with Assistant Executive Director, whose signature on form confirms receipt.