complaint·October 24, 2025

Continued from 9099-A There is no evidence of staff taking R1’s supplies and when LPA questioned other residents about missing supplies, 4 of 4 resident questioned stated that they had not found anything missing from their apartments. A resident (R2) did state that a staff member had asked to borrow some supplies once, but staff did ask and replenished the supplies later. R1’s supplies are not numbered or inventoried so there is no evidence to establish any misuse of R1’s incontinence supplies. Based on interviews of staff and residents and the lack of evidence to support that supplies were taken the allegation that Facility staff did not safeguard resident belongings is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation that Facility did not safeguard resident’s belongings is UNSUBSTANTIATED. (Continued from 9099) The RP stated that R1 was found soiled on multiple occasions while visiting and staff needed to be called in to care for R1 and empty the trash. LPA reviewed documents and found that there was an assessment made on 6/6/2025 which states that R1 is a Level 4.This level provides a resident full assistance with bathing and all activities of daily living. Although the resident has the right to refuse services (which R1 did often, according to 4 of 4 staff interviews), the care plan in effect charged for the increased level of care and staff should have documented refusals and informed responsible party. On 8/7/25, LPA went to the room of R1 to conduct an inspection of the unit. LPA inspected R1’s room without R1’s presence and found the room to be neat and tidy but a definite smell of urine. LPA inspected bedroom and found sheets soiled with possible urine. Administrator and staff explained that R1 was not combative but yelled aggressively and repeatedly refused staff entry when staff tried to help. LPA noted that R1 was not in the room so staff could have changed the linens at that time. On 9/4/2025 LPA went to the room of R1 and found R1 in the unit in bed watching television. The room was neatly arranged but the room smelled (of feces). Both of these visits found R1 had not received the care/services that were listed in the service plan: the resident being clean and odor free. Additionally, the task list report dated 8/7/2025 stated that toileting tasks for caregivers, med techs and LVN/LPN will give reminders, and check bed each morning for soiled linens and if soiled change the bed and to report strong urine odors to DRS, LVN, Medtech and monitor for possible urinary tract infection (UTI). These tasks were not completed on the dates of LPA’s inspections. Based on LPA’s observations, and review of documents the allegation that staff are billing for services not rendered is Substantiated. The finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency a civil penalty assessment. Continued on 9099-D