Complaint Investigation Report

LPA conducted an interview with R1, who reported having a poor experience at the facility overall. R1 provided a timeline of their care: R1 was hospitalized in Temecula, California, in 2025, discharged to a skilled nursing facility (SNF), and subsequently moved to R1’s relevant party’s home. After experiencing another serious health condition, R1 was hospitalized again before being transferred to Yorkshire Village in May 2025. R1 resided at Yorkshire Village for approximately two months in a building consisting of two wings and roughly 60 residents. On July 1, 2025, R1 moved into an apartment and has lived independently since.

During the interview, R1 could not recall the names of the staff members who allegedly treated them without respect and dignity, nor could they remember the specific disrespectful statements made. R1 did, however, recall the name of a nurse who used profane language during their previous stay at the skilled nursing facility. LPA conducted interviews with seven (7) residents, all of whom denied experiencing or witnessing disrespectful behaviors from staff members. LPA conducted interviews with six (6) staff members, all of whom denied treating residents disrespectfully. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated .

It was alleged that facility staff failed to assist resident in a timely manner (within 15 minutes). Information received indicated that staff members took hours to assist Resident #1 (R1). LPA conducted an interview with R1, who stated that staff members would just come to turn off the flashing light and left without proving care when R1 used the pull cord. Staff members often told R1 that they would come back soon but came back much later than 30 minutes. LPA conducted interviews with seven (7) residents regarding the staff response time when their pull cords were used. All residents interviewed stated that staff response time was usually from right away to 15 minutes. All residents interviewed were satisfied with the staff response time. LPA conducted interviews with six (6) staff members, all of whom confirmed the residents’ statements. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated.

A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where a copy of this report was provided.