Complaint Investigation Report

Continued from LIC9099...According to R1’s physician report dated 3/11/26 indicating that R1 was able to care for themselves and perform all personal care. However, based on records review of R1’s admission agreement, it was agreed by the facility and R1 that the facility will assist with daily living activities including hygiene and grooming needs. The facility did not assist R1 with hygiene and grooming needs as agreed in their admission agreement and resulted in R1 sustained lice hair infestation. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D.

Regarding allegation of staff do not ensure facility is free of pests. According to Reporting Party, the facility has experienced several outbreaks of bed bugs over the past year, and these untreated infestations create unsanitary living conditions for residents in care. On 5/26/26, the facility was cited in a case management due to confirmed findings of bedbug bites in a resident in care. Based on records review, R1's physician report dated 03/11/26 indicates that R1 is capable for self-care, but the facility is responsible for laundry services of residents' beddings, R1 also has a roommate resident (R2). The facility provided room treatment log reveals that the last room treated was #11, 5 and 12 located in Wing A back on 3/4/26. Based on interviews conducted with Administrative Assistant and staff (S1) who perform the treatments, after they learned about R2’s complained to their physician, they did wash their linens and clothing, but they didn't threat the room. On 4/4/25, Licensing staff held an informal meeting with facility representatives and LPA have cited the facility to address ongoing bed bugs issues and other unrelated areas of concern, where Co- Licensees agreed to contract a pest control vendor to provide their services to help to get rid of bed bugs at the facility to ensure resident’s health and safety. However, based on interviews and records reviews revealed that the facility still has bedbugs’ issues unresolved and the facility did not treat R1's room after learning of bedbugs. Based on interviews conducted with residents (R1 & R2), R1 was relocated by facility staff to a different room due to bed bugs present in their room, R1 stated that they have washed all their clothing and bed sheets. R2 confirmed that two bed bugs were observed in their shared room and facility staff relocated R1 to a different room, R2 washed all their clothing and bed sheets too. According to R2’s physician report dated 9/28/21, R2 has a history of chronic skin breakdown conditions that needs to be monitored closely to prevent it from getting worse. Based on LPA’s records review and interviews with pertinent parties, it was revealed that the facility is not ensuring to mitigate the exposure of residents in care to bed bugs, this ongoing issue has not been resolved for more than a year. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. An immediate civil penalty in the amount of $1000 will be issued for repeated violation within the last 12-month period.