Complaint Investigation Report

The investigation revealed the following:

Allegation: “Rooms are malodorous”, it is being alleged that residents’ rooms are malodorous. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, moreover, staff explained that housekeepers are continuously working to keep up with the needs of residents. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 6 out of 14 residents agreed with the allegation, moreover they indicated that the facility has incontinent and cigarette smells; 5 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 11 out of 13 witnesses denied the allegation, furthermore, witnesses stated that facility staff clean up after residents; 2 out of 13 witnesses agreed with the allegation. On 01/29/2026, resident rooms were toured and the following was observed: room 267 had strong incontinent smells and room 284 had strong odors. On 04/09/2026, resident rooms were toured and the following was observed: room 242 was malodorous; room 121 had strong incontinent smells; room 126 had strong cigarette odor; room 127 had strong incontinent odor; room 272 had strong incontinent smells; room 115 had strong incontinent smells, resident visitor stopped facility staff in the hallway and informed them that they have been attempting to reach staff and have not been assisted, additionally, resident visitor informed staff the room is “smelling so bad” requesting for the diapers in the trash bin to be removed and the bed sheets to be removed and replaced with clean bed sheets, resident visitor had on two disposable medical face masks, staff called for assistance. Records reviewed revealed the following: the facility has a laundry schedule and cleaning schedule for the Memory Care Unit and the Assisted Living Unit; on 04/27/2026, the facility implemented a plan to ensure that resident appliances (e.g. refrigerators) were to be maintained cleaned, resident rooms will be cleaned and “residents requiring additional support will be flagged for staff follow-up.” Substantiated: Based on observations and interviews, 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 and Chapter 8 are being cited on the attached LIC 9099D.