Allegation: “Staff are not assisting resident with obtaining care”, it is alleged that C1’s doctor prescribed a CPAP machine in November 2025, but the conservators have not received the paperwork needed to have it processed, and the staff has taken no action. A total of (5) staff members including N1 were interviewed and all denied the allegation. S1 and N1 stated they followed the required procedures for obtaining C1’s CPAP machine. However, they do not control any setbacks, such as insurance coverage, out-of-pocket expenses, or the timeliness of the pulmonologist's documentation, as well as the supplier delivery schedule. Documents reviewed revealed that N1 assisted in obtaining C1’s CPAP machine since the pulmonologist prescribed it. N1 also developed and submitted the care plan required by the Regional Center. In addition, staff training on CPAP set-up, use and maintenance has also been planned. Therefore, there is insufficient evidence to corroborate the allegation.

Allegation: “Staff are not following a resident's dietary plan.” It is alleged that the staff were providing C1, who have pre-diabetic eating disorder, with pies, cookies, pancakes, and cakes. It is also alleged that staff do not follow C1’s prescribed dietary plan, leading to weight gain from 202 lbs. to 285 lbs. All staff interviewed denied the allegation and stated that they offer healthy food that matches C1's dietary plan. However, C1 chooses to use their personal money to buy and eat unhealthy food. Staff stated that they constantly encourage C1 to choose healthy food options and to eat in portion sizes, but they cannot force C1 to eat what they don’t want. LPA reviewed the facility’s balanced meal plan created by a dietitian and observed that facility’s food supplies included healthy options such as whole wheat products and meals with low or zero sugar. Staff also maintain a weekly weight record for C1, which also showed that C1 who was admitted in the facility in January 2022, weighed 258.6 lbs. in March 2022 and not 202 lbs. Therefore, there is insufficient evidence to corroborate the allegation.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held and a copy of this report was provided to Hannah Ortega, Administrator in Training.