Complaint Investigation Report

***This licensing report supersedes the previous licensing report dated 05/19/26 in order to clarify information obtained during the complaint investigation and to reissue the citation. The investigation findings will remain the same***

Regarding the allegation: Staff are charging residents for services not provided. It is alleged that the facility is charging a resident for services that were not provided to the resident, for the period, November 2025 and December 2025. Interviews with five (5) of five (5) staff deny the allegation. According to staff, charges for services stated in the resident’s service plan and admissions agreement are charged to residents in care. Staff interviewed reported that staff who oversee R1’s medical visits conducted at the facility by R1’s Physician’s Registered Nurse (RN) stated only observing the visit and not providing any medical treatment or services to R1 during R1’s medical appointment. Staff stated being instructed by ED Hefner to go inside R1’s apartment during R1’s medical appointment and observe the appointment. Interviews with six (6) of ten (10) residents did not corroborate the allegation. Interviews with R1 revealed that R1 did not request additional services be provided by the facility and that R1 is being billed on a monthly basis by the facility for services not rendered. R1 reported that R1 did not sign any documents related to facility staff overseeing R1’s medical visits conducted by R1’s Primary Physician Care Registered Nurse. Documents reviewed indicated that the facility staff charged R1 for a third-party provided medical services in November 2025 through December 2025, and January 2026 through April 2026. The facility has billed R1 for the sum of $340.00 per month for staff observing R1’s medical appointments. During R1’s medical appointments, R1’s Primary Physicians Care Nurse is providing medical treatment to R1’s wound. Facility staff who are present during the R1’s medical appointment relay the information obtained from R1’s Primary Physicians Care Nurse regarding R1’s prognosis to ED Hefner. Review of R1’s Admissions Agreement and R1’s Medical /Financial Power of Attorney (POA) did not reveal that R1 or R1’s POA authorized additional services for R1 under the signed Admission Agreement. The investigation revealed that R1 is being billed for services rendered to R1 during R1’s medical appointment, which is conducted in R1’s apartment by a Third-Party Medical Professional/Registered Nurse. Staff who are present during R1’s medical appointment do not provide R1 with any services and are present to observe R1’s medical appointment.

Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Exit interview was conducted with ED Hefner and copy of 9099, 9099C and 9099D were provided with appeals rights.