complaint·July 2, 2025

Staff did not administer medications to resident in care according to physician's instructions. – Complainant alleges “Staff did not give R1 their medications as needed, and staff mismanaged R1 medications”. Interviews and record review indicate that facility did not properly follow physician instructions regarding medication administration. Based on record review and interview with R1’s caregiver, medication patch used to regulate blood pressure was to be replaced every seven (7) days but was not replaced for approximately two (2) months. Based upon the 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 Lead Staff, whose signature on form confirms receipt. Continued from LIC9099A... Licensee is not ensuring resident’s health and safety. – Complainant alleges “Staff would feed R1 early in the afternoon, but after that R1 was not allowed snacks, etc. - RP added that R1 lost weight while at the facility and RP feels it is because R1 was not provided enough food. Resident fell twice, because, as one of the Home Health Nurses told RP, the bed was too high, and it posed a fall risk”. During visits on 3/24/2025, 5/19/2025, and 6/17/2025, LPA observed staff cooking and feeding residents outside of normal mealtimes if residents said they were hungry, and multiple fridges and cabinets of food were observed stocked. Interviews with residents indicate that they are given plenty of food during mealtimes and are given snacks in between. Record review and interviews indicated that facility was told by Home Health that R1 bed was too high and facility stated they would lower bed to comply. Lack of supervision. – Complainant alleges “There were no staff at the facility during the weekends - the only person on site told RP that they don’t provide care to the residents”. Review of staff schedule shows two staff on duty per day on the weekends as well as overnight staff. Interviews with residents indicate both weekend staff provide care and are able to assist them if necessary. Staff did not follow reporting requirements. – Complainant alleges R1 fell twice and “they also did not report the incidents to RP”. Interviews with R1 and complainant indicate that R1 fell twice at facility with staff having knowledge of both. Review of records indicate that no reports were made regarding falls involving R1. Interviews with staff indicate that they were not aware of any falls. Interviews with residents indicate that they did not witness any falls involving R1 and that staff will provide assistance if they witness it. Record review indicate that Administrator was aware of an incident involving R1, but did not specify what this incident was. Staff did not seek medical attention for resident. – Complainant alleges after falls “resident would lie on the floor for hours until morning staff came, but they would not seek medical attention for R1 after they found them on the floor”. During interview with R1, they claim that they did not receive medical attention after two separate falls, with one resulting in a bleeding cut on right foot. Interview with new caregiver indicate that there is a small, healed cut on the top of R1 right foot. Interview with staff indicate that 9/11 is always called if a resident is injured. Interviews with residents indicate that they receive medical attention should they require it, and staff provide them with basic aid if applicable. Continued LIC9099C... Continued from LIC9099C... Personal Rights. – Complainant alleges “Staff emotionally abused resident, and harassed R1 about paying the bills, etc”. During interviews with complainant, it was alleged that staff verbally harass R1 and spread information that resulted in stress. Interview with R1 indicate that they felt staff was disrespectful towards them and would make inappropriate jokes at R1 expense. Review of records indicate that other visitors also felt staff did not treat R1 kindly. Interview with staff indicate that they treat residents with care and do not verbally abuse them. Interviews with residents indicate that they do not feel staff are rude to them and have not witnessed staff being verbally abusive towards any other residents. Interviews with residents also indicate that they have not witnessed any staff yelling at residents or in general. Based upon observations, record review, and interviews, we have found that 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/complaint is UNSUBSTANTIATED . No deficiencies cited. Exit interview conducted with Lead Staff, whose signature on form confirms receipt.