Complaint Investigation Report

Facility staff stated that they are unable to follow facility designed food menus because of the lack of food supply on the premises. This was observed not in compliance with Title 22 regulation 87555(a) as residents are not provided with a sufficient supply of food of the quantity necessary to meet their needs.

Allegation: Staff locks refrigerator preventing residents to have access.

It was alleged that staff lock the refrigerator preventing residents from having access. This investigation consisted of interviews with facility staff. On 10/28/2025 LPA Hughes conducted interviews with 2 out of 3 facility staff who confirmed that the facilities refrigerator is locked at night per the request of the licensee. This was observed not in compliance with Title 22 regulation 87468.1(a)(3) as residents in care were not allowed to access the refrigerator as it is locked.

Allegation: Facility staff does not have gloves and facility does not follow infection control plan

It was alleged that the facility staff does not have gloves, and the facility does not follow infection control plan. This investigation consisted of facility observations, and interviews with facility staff. On 10/28/2025 LPA Hughes conducted a visit to the facility, during the visit LPA Hughes observed the facility did not have an adequate supply of gloves for all facility staff, LPA observed 1 box of gloves made available for all facility staff. Additionally, according to the facilities Plan of Operation, the facility did not ensure proper reporting of the scabies outbreak to CCLD, residents and their responsible parties, facility staff, and the Sacramento County Dept of Health, The licensee failed to comply with reporting requirements instructed by the Sacramento County Dept of Health on 11/17/2025 as the outbreak was not reported until 11/24/2025. Facility staff were not provided with appropriate and adequate PPE while caring for residents with body lice. Interview with 2 out of 3 facility staff indicated that they were not made aware of the scabies outbreak for 2 weeks following the diagnosis of residents (R3) and (R4). During this time facility staff did not have an adequate supply of PPE. This was observed not in compliance with Title 22 regulation 87208(a)(1). As the facility did not follow the approved Plan of Operation.

As a result, this allegations are SUBSTANTIATED . A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Umesh and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.