complaint·April 14, 2026

Further review shows approximately 15 medication bottles and a bubble pack placed on a wooden chair near the facility cabinets, making them accessible to residents. Although staff reported that medications were secured, the recording also shows that no staff members were awake at the time. Based on the information gathered, the facility staff did not store medications locked and inaccessible to the residents in care. Allegation: Staff were asleep and left residents without supervision while in care. It was alleged that staff were asleep and left residents without supervision while in care. During the course of this investigation, the department conducted interviews and reviewed video recordings. Interviews with two staff members indicated that staff were not asleep and that residents were not left without supervision. However, statements from outside parties reported that a responsible party arrived at the facility and was able to gain entry with assistance from a resident. Upon entry, the responsible party observed S1 seated in the middle recliner with their eyes closed. Recordings obtained from approximately 01/13/2026 further contradict staff statements. The video shows one resident in a recliner, one resident in a wheelchair, and two residents in a separate room. Additionally, upon entry into the living area, a male staff member wearing a dark green sweater and light-colored jeans is observed with his legs propped up and eyes closed, appearing unaware that a recording was being made at that time. Based on the information gathered, the staff were asleep and left residents without supervision while in care. Allegation: Staff did not ensure that hazardous objects were inaccessible to residents in care. It was alleged that staff did not ensure that hazardous objects were inaccessible to residents in care. During the course of this investigation, the department conducted interviews and reviewed video recordings. Based on interviews conducted, it was denied by 2 staff members that they did not ensure that hazardous objects were inaccessible to residents in care. It was stated that residents were unable to access the kitchen without staff knowledge however, further interviews revealed that around 01/13/2026, the kitchen was accessible to residents. During a family visit, items such as knives were observed, and the stove was on. Additionally, the staff member present at that time appeared to be asleep. A review of video footage confirmed that the kitchen was accessible to the visiting family member and showed a large silver knife on a cutting board with two pieces of zucchini beside it, along with the gas stove turned on.Based on the information gathered, the staff did not ensure that hazardous objects were inaccessible to residents in care. Allegation: Staff do not ensure that the facility is kept in a clean condition. It was alleged that staff do not ensure that the facility is kept in a clean condition. During the course of this investigation, the department conducted observations during their visit and conducted interviews. Interviews with two staff members indicated that the facility is maintained in a clean condition. Staff also stated that at the time of LPA Pascua’s visit on 01/16/2026, they were in the process of cleaning. However, interviews with responsible and outside parties reported observing significant clutter throughout the facility. During a subsequent tour conducted by LPA Pascua on 01/26/2026, which included the living areas, dining areas, bedrooms, and backyard, the facility was observed to have a heavy level of clutter across multiple areas, including the kitchen, living spaces, and bedrooms. In the kitchen, there were signs of inadequate sanitation, including cluttered countertops, food items left out, and a sink area with visible debris and buildup. The refrigerator appeared overfilled and disorganized, with food items stored without clear separation. Common living areas contained personal items and laundry that limited available space. The outdoor area also showed disorganization, with various items stored haphazardly and containers holding standing water. Based on the information gathered, the staff do not ensure that the facility is maintained in a clean condition. 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. An immediate civil penalty of $500 was issued for Section 1569.312(e) for facility staff sleeping while supervising the residents. 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. Contact with the residents doctor was also conducted. Further review of the resident’s appraisal was conducted which did not identify a rash on the residents body however interviews were conducted which could not identify when the rash started and revealed contradicting information. Based on the information, there is not sufficient evidence to prove that the resident developed a rash due to staff neglect. 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. There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.