Complaint Investigation Report

S1 stated that they will come to work after Licensee has worked overnight and they observe that nothing has been done overnight. S1 stated that Licensee sleeps during their shift. S1 stated that they have arrived at the facility and resident (R2) will have a full blown diaper, in which they have sat in poop two (2) or three (3) times over. S1 stated that laundry and dishes are not done while Licensee works. S1 stated that they have observed food from the other night still out upon reporting to work. S1 stated that the dishwasher will be full and not started and the care home will have no clean dishes. S1 stated that Licensee does not check the resident rooms at night. S1 stated it is clear that Licensee sleeps throughout their shift.

During visit conducted on February 18, 2026, LPA and Licensing Program Manager (LPM) Lauren Crocker toured the premises and conducted interviews, including R1, Licensee, and House Manager, Stephanie Harmon-Christensen. LPA and LPM also reviewed records for the residents. Interview with Licensee indicated that they did not document a pre-appraisal for R1. Interview with R1 indicated that the facility is understaffed and staffing is inadequate at the facility. R1 stated that only the Licensee works at night and they are concerned about their health. R1 stated that Licensee has muscle spasms and is unable to safely change and reposition R1 in bed. R1 stated that they have almost fallen off the bed while Licensee was attempting to change them. R1 stated that Licensee cannot put R1's diapers on correctly. R1 stated that they can observe that they smell like pee and haven't been cleaned or showered. R1 stated that they go pee every hour and pee twice per diaper change. R1 stated that the diapers being used by the facility are too small. R1 is using two (2) XL diapers but R1 stated that they need a size 5XL. As a result of the visit conducted on February 18, 2026, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1 Personal Rights of Residents in All Facilities (a) “Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.” This requirement was not met based on interviews conducted and observations, which determined that the facility did not ensure to provide R1 with safe equipment to meet the resident's needs, including wearable diapers. Facility was required to obtain an adequate supply of 5XL diapers for resident in need.