complaint·July 17, 2025

Regarding the allegation, “Staff isolates resident in room” it is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and the facility isolated the resident for four weeks. File review revealed that on 05/30/24, staff made R1’s Primary Care Physician (PCP) aware of scabs/sores on R1’s back via email by sending them photos of R1’s back and asked to “please advise”. Once R1’s PCP advised that scabies treatment would be ordered, staff asked if they should take scabies precautions and isolate R1 to which R1’s PCP replied with “Until treatment ideally.” Staff then notified the PCP, that their corporate office was having R1 isolate and release with MD clearance after treatment. PCP responded that they would order HH so they could give clearances after treatment. LPA Cortez observed a doctor’s order for R1 to come off isolation by their PCP, dated 06/26/24. Additionally, interviews conducted with Executive Director Kailey Vandewall, Memory Care Director Denise Wadkins, and Health Services Director (HSD) Ian Gadea on 07/25/24, by LPA Camera, revealed that R1 was placed in isolation due to possible scabies, the doctor told them to isolate the residents to prevent spread to others. In addition, they followed Oakmont protocol for scabies which states to follow doctors orders. Interviews conducted with ED Kailey by LPA Cortez revealed that even though R1 was placed in isolation, they were still continuing the same care it just looked a bit different, staff made sure to be using the proper PPE, and R1 had a 1:1 with them during this period. Although the allegations may have happened or is valid, there is not sufficient evidence to prove that a violation occurred, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegations. “Staff does not ensure resident is provided toiletry supplies, and Staff does not ensure resident's hygiene needs are being met,”; it is the concern of the Reporting Party (RP) that in 2024, R1 was not being provided toilet paper due to clogging the toilet, and that R1 was unkempt and needed increase care with toileting and showering. To investigate the allegation the LPA visited R1 and conducted interviews. On 05/21/25, 05/22/25, and 07/16/25 the LPA observed R1’s restroom with toilet paper accessible to the resident. On 05/21/25, and 05/22/25 the LPA observed R1 to have a neat and well-maintained appearance. Additionally, on 05/21/25, an interview conducted with R1 revealed that they have no concerns, staff help them and treat them well . Report will continue on LIC9099-C 3rd page. Most of the staff interviews revealed that they have never seen R1 unkempt, and they have never seen R1’s bathroom without toilet paper unless they run out and there is additional supply of toilet paper in a locked closet inside the resident’s room. The information obtained during the investigation did not include sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time On the allegation, “Staff does not safeguard resident's personal belongings” it is the concern of the Reporting Party (RP) that Resident 1 (R1) had a lot of expensive clothing brand and on or about 5/30/24, R1 was diagnosed with scabies, and isolated. During this time most of R1’s clothing and bedding was placed in plastic trash bags to be laundered separately in hot water, and the facility lost most of R1’s clothing and bedding or shrunk their clothing. Most of the staff interviewed revealed that they had no knowledge of any missing items for R1, and all clothing and bedding that was laundered were returned. All care staff interviewed denied ever losing or taking any of R1’s belongings. Interviews conducted with ED Kailey revealed that all items were placed back, however there were some clothing that did shrink due to being laundered in hot water, which was part of the Oakmont protocol for Scabies. Additionally, the ED stated that they have offered R1’s POA the opportunity to give the ED a list of items (and their value) that they believe were missing or shrunk and the ED would work with them in processing a refund. File review revealed that R1’s signed Admission Agreement and the facility’s Theft and Loss Policies and Procedures indicate that the facility will maintain an inventory of personal property upon request, unless the resident or responsible party does not wish to complete the inventory. Additionally, the Theft and Loss Policies and procedures indicate that the facility reports lost items of $100 or more to law enforcement and investigate missing items. File review revealed that R1’s responsible party indicated they do not wish to inventory any personal property. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time. Exit interview conducted. Report provided. Regarding the allegation, “Staff does not ensure resident's bathroom is clean”; it is the concern of the Reporting Party (RP) that feces on R1’s bathroom floor was observed. One staff member confirmed that on more than one occasion they saw feces on the floor of R1’s bathroom that looked dry as if it had been there for an extended period and has questioned colleges as to why they did not clean it during previous shifts. On 07/16/2025, the LPA toured R1’s locked bedroom including their bathroom with Executive Director Kailey and at 3:51 p.m. observed dry feces in R1’s bathroom floor, toilet bowl seat with brown skid marks, and the yellow urine stains in the front of the toilet base. Based on the information gathered, the Department has sufficient evidence to support the allegation, therefore the allegation Staff does not ensure resident's bathroom is clean is Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22 (See LIC9099-D.). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights and report copy provided.