Inspector’s narrative
What the inspector wrote
Continued from LIC9099...
Upon completing the visit, LPA went over the LIC9099 report with allegation of Personal Rights to Licensee, when Licensee stood up and got closer to LPA's personal space, pulled down their face mask, raised their voice demanding LPA to disclosed who was the complainant stating that it was their right to know who the complainant was alleging personal rights, and for a moment refused to sign the report acknowledging that they have received this complaint, then Licensee signed the report. During the incident, there were two residents and co-licensee present in the living room, they went to their rooms scared. According to Licensee, the facility is short staff due to staff have been sick since 03/16/26 (Monday) and both Licensees have been working day and night to assist residents in care. Based on interviews conducted with staff (S1, S2 & S3) and residents (R1, R2 & R3) it was confirmed that Licensee raises their voice to staff when residents are present, but no the residents in care. 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), is cited on the attached LIC 9099D. Appeal Rights Given.
The Department will be reviewing to determine if further actions are needed.
Continued from LIC9099A...
Although the medication cabinet was observed unlocked and verbal statements confirmed that medication storage is not secured all the time, there wasn’t any supporting evidence that medication could have been mismanaged by staff. A finding that the allegation of the complaint of staff does not ensure that resident medications are taken as prescribed is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Another allegation was received about staff do not seek medical care for residents in a timely manner. Per Reporting Party, R1 recently (unknown date) experienced a seizure, but no ambulance was called despite their history of epilepsy and other medical issues. Another two co-complainants reported that R1 has been experiencing a persistent rash in their chest for multiple weeks and the facility has not obtained medical care for R1 as of 3/7/26. Based on records review, R1’s after visit summary dated 3/10/26 confirms that R1 was seen for a urinary tract infection (UTI) and Intertrigo which is an inflammatory skin condition. According to R1’s physician report dated 10/11/25, R1 is able to care for activities of daily living including bathing and self-hygiene care. Based on interviews conducted with the Licensee, it is confirmed that R1 is constantly complaining of having UTI symptoms and skin rash, so they were sent to the hospital for further evaluation. LPA conducted interviews with R1, who described that the facility staff are very caring and attempted at anyone. Although it was confirmed that R1 was diagnosed with a skin condition, LPA was unable to determine for how long R1 sustained the rash before the facility was notified about the symptoms, verbal statements did not provide any leading evidence about staff did not seek timely medical attention to R1. A finding that the complaint allegation of staff do not seek medical care for residents in a timely manner is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Regarding allegation of staff do not follow resident's special diet. Per complainant, R1’s special diet was not accommodated by the facility. Per co-complainant, they observed multiple amazon boxes in R1’s room with various food items due to the facility has stopped feeding R1 resulting in R1 having to buy their own food, which is delivered to them. Another co-complainant indicates that staff are not following R1’s special diet, the facility has stopped feeding R1, so R1 has to buy their own food and amazon boxes with food were observed in their room, but R1 does not appear malnourished. During the course of investigation, LPA conducted 10-day visit on 03/19/26, made observations and conducted interviews. Based on observations of facility’s food supply for residents in care. Continued on LIC9099C...
Continued from LIC9099C...
LPA observed a box of two bags of five pounds each of oats, one box of 14 ounces of cream of rice gluten free hot cereal, one bag of two pounds of gluten free seven grain bread, one box of grapes, one box of strawberries, about 10 oranges, two pieces of lettuce and two tomatoes as well as beef and poultry. Also, non-perishable food according to regulations were observed, there was a sample menu posted on the wall with food options. Based on records review, R1’s physician report dated 10/11/25 indicates that R1 has a medical condition of celiac disease, R1’s care plan dated 10/11/25 confirms special diet requirement, where staff have been instructed to follow R1’s special diet. Based on interviews conducted by LPA with facility staff (S1, S2 & S3) and R1, the facility has been following R1’s dietaries restrictions, by offering food options adequate to their special diet, but R1 stated that they don’t like the facility’s food options, including Filipino or Latino food options are not the best choices for them and they would prefer more supplemental food to fit their special diet including more protein shakes and iron, given these reasons led R1 to buy their own supplements to satisfy their nutritional intake. Although the facility provides limited food options for R1’s special diet, the facility has food items available for R1, but R1’s food preferences are different from food choices given. A finding that the complaint allegation of staff does not follow resident’s special diet is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Staff do not provide comfortable living accommodation for residents. Per Reporting Party, there were concerns about R1 feeling cold at times, and the owner of the facility had provided a heater for R1. Based on interviews conducted with staff (S1, S2 & S3) and residents (R1, R2 & R3), it was revealed that R1’s room is colder than other rooms, so R1 was given a portable heater. Residents stated that they are able to adjust the temperature of the home if needed. During LPA’s 10-day visit conducted on 03/19/26, LPA observed the facility was at comfortable temperature of 70 degrees, but R1’s room felt colder than the rest of the home. Based on records reviews of resident’s (R1, R2 & R3) physician reports, the portable heater accessibility doesn’t appear to represent a safety hazard for all residents in care. A finding that the complaint allegation of staff does not provide comfortable living accommodation for residents is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
