Complaint Investigation Report

157206575-2-20-2026-24-AS-SMOA-DRLUZF-20260224150125

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

01/26/2026 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20260126112950

Staff did not keep resident's room at a comfortable temperature

Staff did not ensure resident's diaper was changed timely

Staff did not ensure residents clothes were changed

Due to staff negligence, resident sustained a pressure injury

Staff did not ensure resident's oral hygiene needs were met

Staff are intoxicated while working at the facility

On 02/20/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint inspection and deliver complaint findings. LPA met with staff Yolanda Harness. Licensee John Nobleza who stated unable to attend meeting and authorized caregiver to receive and sign report.

During the course of the investigation, the Department conducted interviews, records were reviewed and toured the facility. The facility temperature is set and maintained within regulations. Residents are checked every 2 hours and brief are changed as needed. Staff assist residents with brushing their teeth every morning and every night. Based on interviews conducted and observation, staff alleged not keeping the resident’s room at comfortable temperature, staff not changing resident’s diaper timely, staff not changing resident’s cloths, staff negligence resident sustained pressure injury, staff not ensuring resident’s oral hygiene is met, and staff intoxicated while working at the facility, the preponderance of evidences standard has not been met, therefore, the above allegations are found to be UNSUBTANTIATED. Exit interview conducted. A copy of this report was provided to staff, whose signature on this form confirms receipt of this report.