Complaint Investigation Report

247209172-5-1-2026-24-AS-SDOE-DUNVNZ-20260602163559

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

09/10/2025 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20250910082422

Administrator Elizabeth Reynaga and Resident Care Director Natalie Levario

Staff speaks inappropriately to residents

Staff do not ensure medication is properly administered

Staff do not ensure resident's incontinence needs are being met

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for subsequent complaint inspection. LPA met with Administrator Elizabeth Reynaga and Resident Care Director Natalie Levario and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Based on observations, interviews conducted and records reviewed, staff was overhead speaking inappropriately to resident. Medication was incorrectly administered by being left in residents drinks and found on the floor and in the trash. Resident’s incontinence needs are not being met in a timely manner. Residents were routinely soaked in urine, with saturated briefs, in wet and soiled bedding.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Administrator Elizabeth Reynaga and appeal rights were provided.