Complaint·October 21, 2025

On the allegation, “Staff refused to assist resident to the bathroom”; it is the concern of the Reporting Party (RP) that on 06/18/24, Resident #1 (R1) needed assistance to go to the bathroom and staff refused to help R1, so the resident called 911 to assist them. It was further reported that Staff 1 (S1) told staff not to assist with R1 because the residents’ bed was too low. Staff interviews confirmed there was an incident where R1 could not be assisted to the restroom. Interview with S1 confirmed that even though they do not recall the exact date, they do recall the incident with R1 and confirmed that staff could not assist R1 to the restroom due to them having a new bed, the bed being too low to fit a Hoyer lift due to the legs being taken off, and the staff not being able to lift R1. S1 further revealed that R1 wanted to be taken to the restroom and S1 told R1 that “they couldn’t help because the Hoyer lift” and that they were happy to change them in bed. Phone Interview with staff 2 (S2) who was present the night of the incident, revealed that even though they did not refused to assist R1 they could not assist R1 to the restroom, there was no Hoyer lift available, and could also not change R1 in bed due to the bed being too low and their back would hurt. Both S1 and S2 revealed that paramedics were called by either R1 or R1’s family member and the paramedics assisted R1 to the restroom. Additionally, S2 revealed that management staff were notified of the incident and they approved for 911 to be called to assist R1. Based on staff interviews, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. On the allegations, “Staff did not do a proper assessment for a level change and Staff did not do a proper rate change”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) and/or their responsible party received a letter that the facility would be raising the cost of rent due to being bought by a new company. On 09/05/24, the facility informed them the new amount would be $3300.13 then five (5) days later on 09/10/24, staff said it would be $6000.00. It was further reported that the levels of care did not change and staff never did an assessment or added anything to the care plan. File review revealed that R1 and/or their responsible person were sent a letter, dated 02/01/2024, informing them of changes to the community’s level of care system. On that letter it was explained that “All existing residents (anyone who has moved into a community before February 1, 2024) will switch to this new care-level plan on April 1, 2024. The actual change will occur at a resident’s first regularly scheduled assessment or change of health condition assessment after April 1, 2024.” File review also revealed that an additional letter dated 02/06/2024 was sent out with detailed information on the number of points that fit into each care level along with the cost per care level. The community now had four levels of care plans and one custom care plan for residents who received 4201 points or higher. This new custom care level would be capped at $6000.00. Furthermore, file Review revealed that R1 was receiving an allowance care discount of approximately $1200 starting in January of 2024, and on November 12 th of 2024 the changes of the new level of care system took into effect for R1 and the allowance care discount was removed. Based on R1’s assessment conducted on 08/01/2024, R1 was assessed at 7,972.08 points. Based on R1’s assessment conducted on 09/10/2024, R1 was assessed at 6,568.50 points and R1’s level of care had decreased. The LPA did not observe anything to suggest the assessment was not done properly. However, per the new care-level plans due to the changes to the community’s level of care system, R1 was now receiving a custom level plan and both assessments were capped at $6000 due to the high amounts of points scored in both assessments regardless of the level of care decreasing from August to September. Based on the information gathered through interviews and file review, the allegations “Staff did not do a proper assessment for a level change and Staff did not do a proper rate change” are deemed Unsubstantiated at this time. Exit interview conducted and report provided.