Based on LPA’s interviews which were conducted and record reviews, 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), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.

Allegation: Staff are unable to communicate effectively

During the review of complaint submitted the complainant stated R1 reported that the staff often spoke limited English or was hard to understand which made staff unable to communicate effectively mostly at night. W1 stated during investigation there was not any problem communicating with the staff. LPA spoke with staff at the facility and did not have any problem communicating.

Allegation: Staff demonstrated inappropriate form of discipline towards a resident

During the review of complaint submitted the complainant stated R1 reported being punished/neglected for asking for help at night, which demonstrated staff conducting inappropriate form of discipline towards a resident. The complaint stated R1 received mental abuse. W1 stated during interview that R1 was never disciplined or

Continued on LIC9099C.

Allegation: Staff did not answer timely to the facility telephone

During the review of complaint submitted the complainant stated the facility staff never answered the facility telephone and the voicemail box was always full. LPA reviewed text messages dated December 20, 2024, between the reporting party and S3 regarding R1’s phone and the facility phone. S3 stated that the staff answers the phone but there were times when the staff is busy and not able to answer or assist R1 with his phone. S3 also stated R1’s family members called and visited the facility and there weren’t any problems.

Allegation: Staff mishandled a resident's medication

During review of the complaint submitted the complainant stated staff continued to administer medication and the medication was increased over the five (5) month period that R1 resided at the facility. Complainant also stated there were no visits to the doctor to justify the increase. LPA reviewed the facility assessment notes, the physician’s orders, and the medication administration (MAR) records from October 2024 until March 2025. LPA observed on the MAR’s and physician reports there were notes where the medicine was changed and discontinued. LPA observed from the assessment notes indicating there were visits and a meeting from the EASE Care nurse

Continued on LIC9099C.

Allegation: Staff interfered with a resident's medical decisions

During review of the complaint submitted the complainant stated R1 verbally expressed he did not want additional medication, but staff continued to administer the medication. LPA reviewed R1’s Advance Health Care Directive notarized November 21, 2024, which named the person responsible for R1’s medical decisions. S3 stated there were not any changes done unless the nurse makes the request and it had to be ordered by the physician. The facility staff cannot increase, decrease, or add any type of medication whether a prescription is needed or if it’s over the counter to any of the residents.

Allegation: Staff did not abide to the admission agreement

During review of the complaint submitted the complainant stated the facility did not abide by the admission agreement. During interviews with S1, S2, S3, and W1 it was stated that the facility did abide to the admission agreement. After reviewing the admission agreement, it was identified that the facility did abide by the admission agreement.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.