complaint·September 3, 2025

feces all over themselves. A review of R1’s 602 physician’s report states that R1 needs assistance with toileting, bathing and grooming. A review of the facility’s August work schedule shows that only two caregivers were working in the memory care unit with 28 residents on the AM shift on 8/4/25. S1 stated that they often find all residents’ briefs soaked at the beginning of an AM shift in the Memory Care unit. S2 stated that a couple of times they had discovered residents with dried feces on their buttocks at the beginning of the AM shift, which S2 said was a sign that caregivers had not changed their briefs in a while. S5 stated that sometimes when the facility was not sufficiently staffed and staff could not respond to call buttons within 10 minutes in Assisted Living, residents had accidents that resulted in soaking through their briefs and bedding. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of staff do not ensure that residents' incontinence needs are met is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87625(b)(3) Managed Incontinences being cited on the attached LIC 9099D. Allegation: Staff speak inappropriately to residents On 5/29/2025 and 6/09/2025, LPA Lindstrom conducted interviews with two staff members, S10 and S12 respectively. Both staff members stated that S9 was very verbally abusive to residents, used bad words, and was aggressive. S10 stated that S9 told resident R2 to go in their f’ing room when R2 would come out at the beginning of S9’s shift. S12 stated that S9 is rude to everyone and calls people retards. On 8/4/25, LPA Lindstrom interviewed F1, who stated that she heard S9 cuss, be vulgar, and tease residents, including saying, “What the f’ are you doing?” to a resident. A review of S9’s file shows that S9 had a history of speaking inappropriately and loudly to residents and to other staff in the presence of residents and their family. Disciplinary records show that management had been meeting with and writing up S9 for at least 8 months. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of staff speak inappropriately to residents is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468(a)(1) Personal Rights is being cited on the attached LIC 9099D. (Continued on 9099-C) Allegation: Staff do not distribute resident's medication as prescribed On 8/4/25, a Medication Administration Report (MAR) for R1 shows that R1 was taking 10 daily medications. The MAR for July shows that medications were not documented as being given on 7/10, 7/11,7/25, and 7/26. R1 is unable to neither confirm nor deny if he received their medications on these days. S4 stated that they had observed empty medicine bottles in the medicine cart that had not been refilled. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of Staff do not distribute resident's medication as prescribed, therefore the allegation is SUBSTANTIATED.California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(a)(4) Incidental Medical and Dental Care is being cited on the attached LIC 9099D. Staff did not ensure resident's dietary needs were met LPA Lindstrom toured the facility on 5/5/25, 5/28/25, 6/9/25 and 8/4/25 and interviewed a total of fifteen staff, ten residents, and four family members. S5 stated that when the facility is not sufficiently staffed, new staff forget to order residents’ meals. F1 stated that R1 was getting their food pureed when first admitted and that R1 started to lose weight after admission. R1’s 602 states that R1 only needs their food to be easy to chew. S1 stated that staff did not meet the dietary needs of R2, who is bedridden. There have been times when R1 was hallucinating due to a side effect of medication and could not eat when his room tray was delivered. Staff put his meal in the microwave and forgot it there. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that staff did not ensure resident’s dietary needs were met, therefore the allegation is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87555(b)(1) General Food Service Requirement is being cited on the attached LIC 9099D. Staff did not answer resident's call button in a timely manner On 5/5/25, LPA Pascua interviewed S7, who stated that the expectation regarding response time to pendant calls was 10 minutes. An analysis of the pendant log for April 2025 showed that the wait 11-20 minutes 21% of the time, 21 to 30 minutes 5% of the time, and over 30 minutes 3% of the time. LPA Lindstrom interviewed a resident R6, who stated that when the facility is not sufficiently staffed, it can take staff up to an hour to respond to calls for help, often times leaving R6 screaming as they cannot reach the call button. R7 stated that staff response time to her call button is usually around 15-20 minutes, although has taken up to 30 to 45 minutes. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that staff did not answer resident's call button in a timely manner, therefore the allegation of is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87464(f)(1) Basic Services is being cited on the attached LIC 9099D. An exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.