Allegation: Licensee does not ensure staff are properly trained. It is alleged that med tech was administering insulin injections even though staff was not licensed as an LVN. Staff interviewed denied the allegation, claiming this was a false statement. Staff denied being a med tech and there are no med tech staff employed in the facility. Staff also stated that there are no residents administering insulin injections. Staff explained that a resident routinely checks their blood sugar with a needle/lancet, however, the resident was the one doing it. Some residents interviewed believed that the staff are properly trained as they know how to handle their day-to-day needs. Documents reviewed revealed that the facility administrator has current, valid certification. Additionally, staff records and required training documentation, including medication training align with Title 22 regulations. Therefore, there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident 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 conducted and a copy of this report was provided to Jacklyn Peng Lee Concepcion, Administrator.

Allegation: Staff do not ensure resident's toileting needs were met. It is alleged that staff double-diapering residents instead of providing appropriate toileting and hygiene care and this explains why the residents get frequent UTI's. During interviews, staff confirmed that they are using double diapers to incontinent residents to prevent leakage, especially at night. S3 stated witnessing a staff double diapering R1-R2 and was concerned about this practice as it poses a high risk for infection. S1 stated that they are unaware of this practice and thought that staff were placing pads inside the diapers and not double diapering. (2) incontinent residents were interviewed and confirmed that staff use double diapers on them. Reviewed documents revealed that the facility did not maintain a record or log for toileting assistance, repositioning or continence care plan. Additionally, incident reports between March-April 2026 showed that (3) residents were sent to the hospital due to Urinary Tract Infection (UTI). And although staff had received personal care training, it was not specified if that training included incontinent care. Therefore, there is sufficient evidence to corroborate with this allegation.

Allegation: Staff inappropriately handled resident. It is alleged that a staff member pinched a resident because he was being combative. Interviewed staff admitted having pinched the resident’s cheek but stated it was just a joke. According to the interviewed staff, "I pinched him on the face, but as a joke only. I joke with him everyday." Staff also stated that it was not done firmly as they have no intention of harming the resident, and no injury was reported. S3 stated that they witnessed the incident but did not see an injury to the resident. During the visits on 05/28/2026 and 06/08/2026, LPA did not observe any physical marks such as redness or bruising on R1's face or arms. Interviewed residents were unaware of the incident and did not comment on the allegation. Therefore, there is sufficient evidence to corroborate with this allegation.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Administrator, Jacklyn Peng Lee Concepcion, Administrator along with the Appeal Rights.