Complaint Investigation Report
Allegation: Facility staff do not ensure resident hygiene needs are met. LPA and LPM conducted interviews and observations as noted above. Based on observation conducted on 8-28-25, it was revealed that various rooms in memory care were missing soap and toothpaste products necessary for maintenance of proper hygiene. Additionally, it was observed on 8-28-25, that resident in room #8 was not provided an electric razor despite request and observed to be in need of grooming. LPM also observed various residents not groomed properly within memory care unit. As a result, the preponderance of evidence standard is met and this allegation is SUBSTANTIATED.
Allegation: Facility staff do not ensure that the resident bed is working. LPA conducted observation on 8-28-25 and observed bed in room #3 to not be operating properly. Specifically, foot of bed will raise, and head of bed would not raise. It was revealed through interview that bed currently in room #3 was placed in room after hospice company picked up a bed previously in the room. Additionally, it was observed by LPM that room #55 contained an air mattress for a resident which was not functioning properly. As a result, the preponderance of evidence standard is met and this allegation is SUBSTANTIATED.
Allegation: Facility staff denied residents going on outings . LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that on 7-28-25, staff5 (S5) disclosed to a family member via email that per Power of Attorney (POA), family member "cannot take {resident1 (R1)} anywhere." It was further revealed that R1 maintains his rights to visitation with family of choice. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.
As a result of this investigation, citations are issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with licensee designee and a copy of this report was provided. Appeal rights and LIC 811 provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction