complaint·May 21, 2025

Continued from LIC 9099 On 04/10/2025, LPA Conway, conducted an initial complaint visit. During that visit, LPA conducted a tour of the physical plant, obtained copy of the resident and staff roster and obtained pertinent information relevant to the investigation. Between 10:30 A.M. and 2:30 P.M. LPA conducted interviews with the ED, Maintenance Director, Director Culinary Services, four (4) residents and two (2) staff members. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined: The complaint alleges that the facility provides poor-quality food, limited quantities, and lacks water access to residents. The reporting party expressed concern that facility is experiencing food and water shortage. Interviews with residents revealed mixed feedback regarding food service. Some residents were frustrated by occasional unavailability of specific menu items -such as vanilla ice cream, beets and sourdough bread- despite being listed on the menu, while others shared positive comments, stating that the quality of the food has significantly improved since the facility hired a new Culinary Director. All residents interviewed confirmed that meals have consistently been served as scheduled, with adequate portions and able to get second servings upon request. Additionally, snacks are also accessible at the “Anytime Café” between meals. Interviews with the ED and a walk-through of the facility conducted on 04/22/2025, confirmed that the facility has not experienced shortages of food or water. A large supply of purified water in a storage room, bottled waters and multiple water dispensers were observed. Some water dispensers were low or empty. The LPA discussed this with the ED, who agreed to instruct staff to monitor and refill the dispensers regularly as part of their rounds and ensure regular refills. Two (2) new water dispensers were also installed in the theater room and the upstairs activity room to improve access to residents on all floors. Regarding concerns about food shortages, the Director of Culinary Services reported regular food deliveries twice a week, with occasional substitutions due to vendor shortages, but stated the facility has never run out of food. Record review reflects that the facility receives food deliveries from Sysco every Tuesday and Friday. Continued on LIC 9099-C Continued from LIC 9099-C The LPA reviewed purchase orders dated from 03/11/3035 through 04/08/2025. During the review, it was observed that cases of 8-oz water bottles are consistently being ordered, with regard to food items, it was noted that when the distributor is out of stock on a particular item, it is automatically substituted with similar item to ensure the facility continues to receive necessary supplies without interruption. Inspections showed ample fresh, canned and dry food supplies, including emergency stock. The LPA addressed resident’s concerns about discrepancies between menu descriptions and actual meals with the Ed. The LPA also recommended ordering more of popular items like vanilla ice cream to reduce substitutions and meet resident preferences. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff does not ensure food is of good quality and does not has sufficient supply of food in the facility for resident in care” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. Continued from LIC 9099 The complaint alleges that the facility is not kept in good repair, as the main elevator (large car elevator), has been restricted from use by residents in care since February 2025, per management’s decision. The reporting party is concerned that this ongoing issue poses a significant inconvenience for residents who use wheelchairs or other mobility devices, as they are required to travel across the building to access the only remaining operational, smaller elevator. Interviews with ED revealed that the facility has two (2) elevators, with at least one (1) remaining operational at all times. The main elevator was taken out of service for safety reasons due to a noticeable bump occurring between floors, which posed a fall risk. The ED further explained that a third-party vendor (TK Elevator Corporation) was contracted to perform the necessary repairs, but due to the elevator’s age, a specific part (piston) had to be manufactured and shipped. Although the repair was originally scheduled for early April, it was delayed and rescheduled several times. During today’s visit LPA observed that the main elevator is still out of order, however, per ED elevator is under repair and it will be finalized by 5/23/3025. Interviews conducted with residents and visitors revealed that the current elevator situation has caused considerable inconvenience, particularly for residents living near the main elevator who now have to walk longer distances to access the functional elevator. Several residents expressed frustration, particularly during peak times like meals, when wheelchair and scooters users reduce the available space in the smaller, working elevator, leading to long wait times. Concerns were raised about accessibility and the need for reliable elevator service to ensure safe and reasonable access to common areas. Furthermore, records confirmed that elevator issues were reported to the attention of both the ED and the Maintenance Director during council meetings. On 02/11/2025, it was announced that the main elevator would be taken out of service. On 03/11/2025, it was reported that the repair was both complex and costly, with a hopeful completion date of 04/01/2025. However, on 04/08/2025 the estimate repair date was revised to 05/01/2025. Continued on LIC 9099-C Continued from LIC 9099-C During facility visits conducted on 03/20/2025, 04/10/2025 and on 04/22/2025, the LPA observed “Temporary Out Of Service” signs posted at the front desk and on the double doors leading to the main elevator. Facility records show the repair work order for repair was initiated on 01/22/2025. On 04/17/2025, the LPA requested email correspondence with the vendor, however, the information provided lacked specifics details about the diagnosis or scope of the required repair. On 4/28/2025, the LPA sent a follow-up email requesting additional documentation, including a formal diagnosis, invoice and explanation for delays such as, the expected delivery time frame and any official communication from the supplier verifying that the part was backordered or required manufacturing. As of the date of this report, the LPA has not received the requested documentation. The only response received was an email stating that the repair was first rescheduled for 05/12/2025, then corrected to 05/19/2024. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation of “Facility is not kept in good repair”. Therefore, the above is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.