Complaint Investigation Report

During a visit to this facility on 3/7/25, CCLD staff observed food which was improperly covered, insufficient food supplies, unclean refrigerators, and freezer burned food. In recent interviews, a resident (R1) said the facility’s food had been “poor quality” several months ago, but had since improved.

LPA Moleski visited this facility during daytime hours on 5/5/25 for a period of approximately 6.5 hours. LPA Moleski visited this facility a second time during daytime hours on 5/20/25 for a period of approximately 5.5 hours. During these time periods, LPA Moleski did not observe most residents engaged in meaningful activities. LPA Moleski did observe one resident with dementia playing with sensory stimulation devices, but did not observe any other group or individual activities ongoing. Residents observed during these time periods were largely either watching television or sitting outside. LPA Moleski interviewed two residents who were able to coherently respond to questions and who were not diagnosed with any sort of cognitive impairments (R2 and R7). R2 said that there are board games at the facility, but they are not played. R2 did not identify any other activities that are available for residents. R2 said that activities are not possible due to the condition of the other residents of the facility. R7 also said there are games around the facility, but they are not used. R7 had not observed other residents engaged in meaningful activities. LPA Moleski interviewed a staff member (S3) on the same date LPA Moleski interviewed R7. S3 claimed that a board game had been played with residents the day before. In an interview, R6’s RP said that there was “not a lot of stimulation” at the facility, that staff “don’t seem to engage them in activities,” and that when they visit, R6 is typically watching television.

The department has determined the following as it relates to the allegations that staff do not ensure that residents in care are provided with food that is of good quality and that staff do not provide activities for residents in care:

Based on interviews and observations, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Sections 87555(a) and 87219(a). An exit interview was held with Clark. Appeal rights and a copy of this report were left with Clark.