Complaint·November 6, 2025

Allegation "Unqualified staff are administering medication to residents:" The complaint alleges that staff administering medications to the residents lack the training to do so and "know nothing" about medications. LPA reviewed four (4) employee files of those staff designated to administer medications. Two (2) of the four (4) staff hold valid RCFE Administrator certificates and therefore have verified training in medication administration. All four (4) of four (4) staff have eight (8) hours of additional documented training in medication administration for the current calendar year and the previous year. As this facility recently changed ownership, all training was conducted with the previous licensee. LPA confirmed through interview with residents and staff that only the four (4) staff administer medications and no one else. Management further clarified that all staff, including kitchen, housekeeping, and maintenance are all trained in medication administration in case of emergency. The information obtained during the investigation did not include sufficient evidence 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. Allegation " Licensee does not ensure that employee records are accurate:" LPA reviewed four (4) staff records during today's visit. All four (4) staff files reviewed contained all documents required per Title 22 regulation, including but not limited to: health screenings, TB test results, background clearance, and training records. Interview with management revealed that under the prior ownership, the records did need some work, however, when the new licensee took over, management ensured all staff records are complete and accurate. The information obtained during the investigation did not include sufficient evidence 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. Allegation "Facility staff are forcing residents to work:" LPA interviewed staff, management and residents related to this allegation. Interview revealed that the facility does have an incentive program. Residents can request to sign up for a task and the residents are paid for each day a chore is completed. Work assignments include table setting, bussing, meal service, and sweeping outside. Residents interviewed that participate in the incentive program reported they are happy they have an option to keep them busy and engaged. Residents stated the program is a good thing for them Report Continued on LIC 9099-C (p.3) and they are glad to be able to participate. Both residents and staff denied that anyone is "forced to work." LPA also interviewed residents that do not participate in the incentive program who indicated the program is optional and they have decided not to participate. The information obtained during the investigation did not include sufficient evidence 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. Allegation " Facility staff do not provide quality meals to residents:" LPA reviewed the facility's four (4)-week menu, which consists of a variety of foods in all food groups. Interview with staff revealed the facility does consult with a dietician, who has created the menu to be nutritionally balanced to meet the needs of the residents in the facility. LPA observed today's lunch, which consisted of a chicken quesadilla, soup, salad, dessert and a choice of beverage. LPA also observed a variety of foods in the facility pantry, refrigerators and freezers. Food is delivered weekly through Sysco. Interviews with residents revealed the food is adequate. Some residents commented that the food is more processed than they prefer, however it is varied in nature and many of the meals are good. All residents and staff interviewed indicated residents can always request an alternate to the menu item if they prefer. Breakfast, lunch, dinner, and three (3) snacks are served daily. The information obtained during the investigation did not include sufficient evidence 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. Allegation " Facility staff do not properly disinfect dishes:" During today's visit, LPA observed kitchen staff utilizing a three (3)-step process for cleaning the dishes after lunch service. In one sink, a staff was observed scrubbing the dishes with soap and water. In another sink, staff was able to rinse the dishes and then the third sink is utilized to disinfect the dishes. Staff interviewed stated the the kitchen staff do wash with soap and disinfect all dishes used in food preparation and service. Residents interviewed stated the kitchen staff wash the dishes right away after meals are completed and also indicated they have never seen any dirty dishes being used. The information obtained during the investigation did not include sufficient evidence 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 Report Continued on LIC 9099-C (p.4) allegation is deemed UNSUBSTANTIATED at this time. Allegation "Facility staff do not assist residents with hygiene:" The complaint alleges that residents are dirty, not showering and their hygiene needs are not met. Interviews with staff and residents revealed that most residents in the facility are independent and do not require assistance with showers. There is a shower schedule for the six (6) residents identified who do need assistance taking showers. These residents are assisted twice a week. All other residents shower independently. All residents are encouraged to shower as often as they prefer, with a minimum of two (2) showers per week. Staff stated there are residents who refuse to take showers, but that is their right to refuse. If residents regularly refuse, their case manager, conservator (if conserved) and doctor are all notified. The team then works together to come up with a solution for that individual resident. During today's visit, LPA observed all residents appeared to be clean and their hygiene needs met. The information obtained during the investigation did not include sufficient evidence 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. Allegation " Facility staff do not ensure residents have clean clothing:" LPA interviewed residents and staff related to the facility's laundry service and clothing changes. Residents interviewed stated their laundry is washed weekly on a scheduled day, which includes all linens and clothing. Residents can request additional laundry service if needed as well. Laundry staff is scheduled from 07:00AM to 11:00PM every day. Laundry staff were observed washing, drying and folding resident laundry during today's visit. LPA obtained a copy of the laundry schedule indicating the days of the week each resident's laundry is assigned. Residents and staff stated all residents are encouraged to put on clean clothing each day, but there are some residents that refuse. Residents stated it is their right to refuse to change clothes. The information obtained during the investigation did not include sufficient evidence 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. No citations issued. Exit interview conducted. A copy of today's report was provided.