complaint·February 27, 2026

However, 5 out 5 staff members report that the residents may have unwitnessed falls as they cannot prohibit the resident from falling but can assist to mitigate the falls. In addition, a review of the resident’s care plan dated on 05/26/2025, states that the resident may be a fall potential however the fall risk was scored as 0. This was acknowledged and signed by the resident responsible party on 05/26/2025. Based on the information gathered, there is not sufficient evidence to prove that staff did not provide adequate supervision to resident resulting in resident falling. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not assist with resident’s bathroom needs. It was alleged that staff did not assist with resident’s bathroom needs. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted with 5 staff members. 5 out 5 staff members deny that they did not assist with the resident’s bathroom needs. 5 out 5 staff members state that they assist residents as needed. 5 out 5 staff members state that residents may have to wait for a couple minutes to get assistance however will always assist the residents. An interview with 5 residents were conducted. 5 out 5 residents denied not being assisted with their bathroom needs. Based on the information gathered, there is not sufficient evidence to prove that staff did not assist the residents with their bathroom needs. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. However, a review of the facility’s Plan of Operation, page 54, Reporting Requirements (6)(d), states: “any incident which threatens the welfare, safety or health of any residents, such as the following: falls…” must be reported. Additionally, page 55, Medical Emergencies, states: “In an event of a non-serious emergency…the physician will be contacted immediately for advice regarding treatment, the physician’s recommendations will be followed and documented, and the family contacted to report the incident.” Based on the information obtained, facility staff did not notify the resident’s responsible party of the incident. As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit. Allegation: Staff did not properly discharge resident It was alleged that the staff did not properly discharge resident. During the course of this investigation, LPA Pascua conducted interviews and reviewed facility records. Based on interviews conducted, it was learned that this resident was at the facility for 1 week for respite care with assistance from Hospice. It was stated by facility management that due to the resident being on respite, the facility would be notified by the responsible party or hospice when the resident would leave. It was stated that the family would pick the resident up. A review of the facilities records show that the facility discharged the resident’s medication and belongings with the responsible parties signature acknowledging that they had obtained everything for the resident. Based on the information gathered, there is not sufficient evidence to show that the staff did not properly discharge the resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of the report was given to Jackie Hernandez.