complaint·March 26, 2026

Regarding the allegation:1.) Facility staff do not respond to residents call buttons in timely manner. It was alleged that Resident #1 (R1) had waited for more than 30 minutes to get assistance, leading to R1 being left in soiled clothing. The LPA was provided with pictures dated 12/29/2024, of R1 being left in soiled diaper and clothing. During the time of R1 being left in soiled diapers, it was brought up to the Wellness Director (WD) at the time, Gloria Morales and the ED at the time, Ken Mahler. Interviews conducted with staff revealed that during the time of the complaint, there were staff shortages and response times were longer than 20 minutes. Interviews with staff confirmed that R1 had been left in soiled pull ups on occasions. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff do not respond to residents call buttons in timely manner” is deemed Substantiated at this time. 2.) Facility staff are not dispensing medication as prescribed. It was alleged that facility staff were not properly assisting Resident #1 (R1) with their medication, as R1’s medication was found on the floor multiple times. During the initial visit, the LPA could not conduct a medication audit for R1, as R1 no longer resided at the facility. The LPA requested R1’s medication records. Per record review, on 12/26/2024, R1’s physician ordered R1 to start taking Macrobid 100 mg (twice daily for 7 days) and Phenazopyridine 200 mg (three times daily for 5 days). On 12/27/2024, it was noted on R1’s medication pass history that R1 only took Macrobid 100 mg once and Phenazopyridine 200 mg twice. The medication pass history did not document the reason for the missed medications. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff are not dispensing medication as prescribed” is deemed Substantiated at this time. The same deficiency was cited for another complaint on 03/26/2026 therefore it will not be duplicated on this complaint. 3.) Facility staff did not seek timely medical attention for resident in care. It was alleged that during December 2024, R1 was not receiving timely medical attention which resulted in the hospitalization of R1. Per record review, on 12/27/2024, R1’s physician ordered “Urgent Home Health (HH) order to administer suppository and blood sugar checks” as well as “blood sugar checks once daily in the morning before breakfast.” During the initial visit, LPA Peraldi conducted a file review of R1’s records. There were no HH documents or plan of care for R1. Interviews with the previous ED and WD revealed that they were not aware of R1 needing HH in December 2024. Interview with R1’s family member revealed that they believed R1’s blood sugar was not getting checked. Continued on LIC 9099-C. R1 was sent to the hospital soon after (no specific date or reason was provided) and returned to the facility on 01/22/2025 under hospice. The facility did not produce proof that R1 was getting their blood sugar check per physician order. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff did not seek timely medical attention for resident in care” is deemed Substantiated at this time. 4.) Facility staff do not ensure resident's hygiene needs are met. It was alleged that R1’s hygiene needs were being neglected as R1 did not receive assistance with showers. The LPA was provided with text messages and pictures of R1’s hygiene concerns from 2024. The text messages demonstrate R1’s hygiene concerns being brought to the WD at the time and no direct response was given to R1’s family. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff do not ensure resident's hygiene needs are met” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). The Interim ED was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegation: 1.) Facility staff do not keep resident rooms clean and orderly. During physical plant tours, the LPA observed multiple resident rooms and restrooms which appeared clean. Interviews with staff and interim ED explained that there are three (3) housekeepers, one (1) for the Memory Care (MC) side and another for the Assisted Living (AL) side, and another part time housekeeper. Interviews with housekeepers revealed that they have a schedule and are assigned to clean different rooms each day. Housekeeping staff explained that each resident room gets cleaned once a week or as needed. Interviews with residents during the time of the complaint did not reveal any concerns regarding the cleanliness of their rooms and facility. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.