Allegation: Staff did not ensure the resident attended their medical appointments

It is being reported that staff rescheduled R1’s appointments to coincide with staff schedules. LPA Felisa Shirley reviewed R1’s appointment tracking sheet and observed that R1 had 2 appointments in February 2026. Appointments scheduled for 2/5/26 and 2/20/26. The appointment for 2/20/26 was rescheduled for 4/29/26. Staff for Villa Redondo Care Home provided transportation for the appointment on 2/5/26. There were no appointments scheduled in March 2026. R1 had 1 appointment for April 2026 on 4/29/26. Staff for Villa Redondo Care Home provided transportation for the appointment on 4/29/26. R1 returned to the facility on 4/29/26 from doctor’s appointment and a family member arrived to the facility to accompany R1 to another doctor’s appointment. Per interview with S1 on 4/30/26, he does not have information regarding the second appointment on 4/29/26. Per interview with S1, staff ensures that there is staff available to accompany R1 to all doctors appointments when given notice.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not ensure the resident attended their medical appointments,” therefore, the allegation is unsubstantiated.

Allegation: Facility elevator is in disrepair

It is being reported that facility’s elevator breaks down and is a hazard in case of an emergency. On 4/30/26, LPA Shirley toured this facility and observed that there are 4 sets of stairs and one elevator. LPA Shirley notes that elevator is working today, 4/30/26. LPA Shirley reviewed the service log for the elevator which was last serviced, 4/21/26. LPA notes that the elevator is serviced monthly by Delta Elevator Company, Inc. Per interview on 4/30/26 with S1, the elevator is paused to service the elevator once monthly. Per S1, the staff and residents are notified when the elevators are being serviced and notices are also posted.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility elevator is in disrepair,” therefore, the allegation is unsubstantiated.

Con'd 9099-C

It is being reported that R1’s roommate R6 has fallen multiple times due to understaffing at this facility. R6 was admitted to this facility on 8/20/21, per Admission Agreement. Since R6’s day of admission, there are 16 Special incident Reports, (SIR’s), which include 3 falls. Per Resident Assessment form dated, 1/9/26, R6 is a fall risk. Resident is under C&V Hospice service. Per Individualized Service Plan dated 1/9/26, resident requires status checks for safety purposes, rail on R6’s bed, and requires full assist/escorting to all meals and events. R6 was transferred to another room on 4/9/26.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not provide proper supervision to resident in care,” therefore, the allegation is unsubstantiated.

Allegation: Staff did not safeguard the resident’s personal items

It is being reported that after R1’s roommate had visitors, R1’s phone charger was missing. LPA observed that R1’s Residents Personal Property and Valuables form was not filled out however, it was signed by R1. Per interview with S2, R1’s phone and charger were both in the Med Tech room charging. When S2 discovered that the phone was not charging, she replaced the charger. Both phone and charger were given back to R1.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not safeguard the resident’s personal items,” therefore, the allegation is unsubstantiated.

Con'd on 9099-C

It is being reported that a specific Med Tech was rude and condescending to residents. Per interview with R1 on 4/30/26, she indicated that staff are usually easygoing and that she had never had the experience of a member of staff speaking to her inappropriately. Per interview with S5 on 4/30/26, staff are usually speaking loudly as many of the residents are hard of hearing. S5 stated speaking loudly may be misinterpreted as being rude, however staff are trying to make sure that the residents hear them.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff spoke inappropriately to resident in care,” therefore, the allegation is unsubstantiated.

Allegation: Staff did not provide proper medication assistance to residents in care

It is being reported that a conversation was overheard that residents were not receiving their prescribed medication. LPA Shirley requested and was provided a copy of the name of residents that are prescribed the medication, Norco. There are 8 residents that are receiving, Norco. On 4/30/26, LPA Shirley reviewed the residents receiving Norco Medication Administration Record, (MAR). Upon review of the MAR’s, LPA Shirley observed that the medication, Hydrocodone for Norco is prescribed as a Pro Re Nata (PRN) which means, “As the Need Arises.” LPA Shirley observed that the medication was administered as needed with the initials of the staff that administered the medication.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not provide proper medication assistance to residents in care,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator, Jesus Chavez.