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32 | The investigation revealed the following:
Allegation: “Rooms are malodorous”, it is being alleged that residents’ rooms are malodorous. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, moreover, staff explained that housekeepers are continuously working to keep up with the needs of residents. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 6 out of 14 residents agreed with the allegation, moreover they indicated that the facility has incontinent and cigarette smells; 5 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 11 out of 13 witnesses denied the allegation, furthermore, witnesses stated that facility staff clean up after residents; 2 out of 13 witnesses agreed with the allegation. On 01/29/2026, resident rooms were toured and the following was observed: room 267 had strong incontinent smells and room 284 had strong odors. On 04/09/2026, resident rooms were toured and the following was observed: room 242 was malodorous; room 121 had strong incontinent smells; room 126 had strong cigarette odor; room 127 had strong incontinent odor; room 272 had strong incontinent smells; room 115 had strong incontinent smells, resident visitor stopped facility staff in the hallway and informed them that they have been attempting to reach staff and have not been assisted, additionally, resident visitor informed staff the room is “smelling so bad” requesting for the diapers in the trash bin to be removed and the bed sheets to be removed and replaced with clean bed sheets, resident visitor had on two disposable medical face masks, staff called for assistance. Records reviewed revealed the following: the facility has a laundry schedule and cleaning schedule for the Memory Care Unit and the Assisted Living Unit; on 04/27/2026, the facility implemented a plan to ensure that resident appliances (e.g. refrigerators) were to be maintained cleaned, resident rooms will be cleaned and “residents requiring additional support will be flagged for staff follow-up.” Substantiated: Based on observations and interviews, 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 and Chapter 8 are being cited on the attached LIC 9099D. |
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32 | The investigation revealed the following:
Allegation: “Unqualified staff are providing medication assistance to residents in care”, it is being alleged that untrained staff are providing medication assistance to residents in care which have resulted in medication errors. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, moreover, staff indicated that staff are trained in medication administration and staff are not aware of any medication errors. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation and 11 out of 14 residents denied the allegation. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Records reviewed of Medication Administration Trainings from 01/2025 to 01/2026 revealed the following: Medical Technicians (MedTech’s) and Licensed Vocational Nurses (LVNs) received in-service trainings on Medication Destruction, Receiving Medication, Centrally Storing Medication, Expired Medications, Managing Orders, Communication Documentation, Refusal of Medication, Counting Narcotics, Medication Crushing, Discontinued Medication, MAR Documentation, and so on. Records reviewed revealed that in 2026 MedTech’s received a Certificate of Completion for successfully completing 8 hours of in service of Medication Administration Techniques & Medication Forms Documentation. Records reviewed revealed that LVNs have a current Vocational Nurse License. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
An exit interview was conducted, and a copy of this report was left with the Executive Director, Suzette Johnson. |
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32 | Allegation: “Facility is not equipped with sufficient hygiene supplies,” it is being alleged that residents are not provided with sufficient hygiene/bathroom supplies such as paper towels, hand soap, and so on. Interviews conducted with S1 to S13 revealed the following: 13 out of 13 staff denied the allegation, staff explained that residents receive a clean hand towel but do not receive paper towels and there are no electric hand dryers in the resident bathrooms. Interviews conducted with W1 to W13 revealed the following: 13 out of 13 witnesses denied the allegation. Interviews conducted with R1 to R14 revealed the following: 3 out of 14 residents were unable to corroborate the allegation; 2 out of 14 residents denied the allegation; 9 out of 14 residents agreed with the allegation, furthermore, they explained that the facility provides them with toilet paper and a hand towel, and at times they provide them with hand soap, moreover, residents explained that they purchase their own hand soap and hygiene supplies. Observations of resident rooms on 01/29/2026 and 04/09/2026 in the Memory Care Unit and Assisted Living Unit revealed the following: Resident bathrooms are provided with a hand towel even if there are two residents per room; residents are not provided with paper towels nor an electrical hand dryer. There were five bathrooms that did not have hand soap, and there were several bathrooms that did not have toilet paper and a hand towel. Substantiated: Based on observations, interviews and record review, 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 and Chapter 8 are being cited on the attached LIC 9099D. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/03/2026
Section Cited
CCR
87468.1(2) | 1
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7 | Personal Rights of Residents in All Facilities
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by: | 1
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7 | Executive Director has agreed to create a plan to ensure that residents are provided with comfortable accommodations by maintaining a facility that is clear of malodors. Plan should include the following: removal of used incontinent supplies from resident rooms, the number of times staff will go into |
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14 | Based on observations and interviews the licensee did not comply with the section cited above by not providing residents with comfortable accommodations by not having rooms free of malodors which included incontinent odors, cigarette smoke odors, etc. which poses an immediate health, safety or personal rights risk to persons in care. | 8
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14 | residents rooms to remove items that are/can cause malodorous and smoking prevention inside the facility. The Executive Director will train staff on said plan.
Email plan & trainings to Socorro.Leandro@dss.ca.gov |
Type B
08/03/2026
Section Cited
CCR
87307(a)(3)(C)(D) | 1
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7 | Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. (D) Hygiene items of general use such as soap and toilet paper.
This requirement is not met as evidenced by: | 1
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7 | Executive Director has agreed to create a plan to ensure that the use of common (hand) towels are prohibited in the facility. And residents have hand soap, toilet paper, and hand drying material (e.g. paper towels, hand dryer, individual hand towels) available to them at all times. |
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14 | Based on observations and interviews the licensee did not comply with the section cited above by providing residents with a common hand towel and not ensuring that residents had hand soap and toilet paper are available to them at all times which poses an immediate health, safety or personal rights risk to persons in care. | 8
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14 | Email plan & trainings to Socorro.Leandro@dss.ca.gov |