complaint·September 26, 2025

(Continued from 9099) LPA conducted an interview with S1 who verified by email, that verbal notification was given to the responsible party but a written copy was not given due to the report including information of another resident. LPA notes that this confidential information could have been redacted and a copy of the Incident Report given to the responsible party of R1. Based on LPA's interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8). Continued from 9099-A Licensing Program Analyst (LPA) Nakagawa interviewed RP who stated they brought in cleaning supplies and cleaned the floor up as staff stated they were unable to clean the floor. LPA spoke with S1 who stated staff informed S1 of the issue and that staff did clean the area when it occurred on 5/11/2025. S1 reported the maintenance crew attended the area again on 5/12 /25 in the morning using the carpet cleaning machine. Photos submitted show clothing on the floor of the room but there is no indication of how long clothing was there and does not provide substantial evidence that the facility was not maintained to be sanitary. LPAs Nakagawa and Cuadra inspected the facility on 06/03/25, 8/22/25 and 9/18/2025 and found the facility clean and sanitary. LPA Nakagawa conducted interviews with 4 staff and 2 family and found that 6 out of 6 found the facility to be clean and sanitary. Based on interviews conducted and photos received the allegations that Staff did not maintain a facility sanitary and Staff did not provide resident housekeeping service are unsubstantiated. Although the allegations may have occurred there is not enough evidence to substantiate the allegations therefore the allegations are unsubstantiated. The complaint alleges that Staff do not follow resident’s care plan. The complainant states that staff did not follow R1’s care plan and that for three days, staff had R1’s personal care items locked away in a cabinet in the bathroom. RP stated that on 5/11/2025, they observed that R1 had worn socks for three days, hair was a mess, teeth were not brushed and R1 was not wearing their hearing aids. RP stated that R1 had worn socks for so long legs were swollen. RP stated that R1 had to wear compression socks to resolve the matter. RP stated that staff did not take off R1’s hearing aids at night per instructions in his care plan, resulting in R1’s hearing aids becoming lost underneath his bed . ( Continued on 9099-C2 ) (Continued from 9099-C) LPA reviewed the ADL Care Sheet which states that R1 received a bed bath on 5/9 and 5/12 by hospice and 5/15, 5/19, 5/22 and 5/25 during the AM shift by either facility care staff or hospice care. It is documented that teeth were brushed in the AM and PM by care staff. Swelling of legs is mentioned on the Intake Sheet dated 5/8/2025 (the date R1 moved into the facility) and on the Shower Sheet on 5/9/2025. Hospice attended R1 regularly and did not mention any signs or symptoms of pain or swelling until 5/15/2025 when Ted Hose were prescribed to manage the swelling. LPA’s review of care plan shows that care staff were to remove hearing aids each night. Responsible party stated that hearing aids were found under the bed on three occasions. LPA conducted interviews with care staff regarding hearing aid care. 4 of 4 staff verified that hearing aid care and maintenance is regularly conducted during AM and PM care and it is documented in the MAR. Based on LPA’s interviews conducted and record review the allegation is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to substantiate the allegation therefore the allegation that Staff did not follow resident’s care plan is unsubstantiated. Report reviewed with Administrator.