The investigation revealed the following:

Facility staff deny the allegation. Interviews with S1-S2 indicated, resident arrived to the facility from skilled nursing hospital with a five-day supply of medication due to R1's new order not being filled till 5/20/25 per pending order status on R1’s physician order documents. Staff stated R1’s family member, delivered medication from pharmacy not contracted with the facility due to R1’s medical insurance being outside of facility’s network before the five-day supply finished. Staff interviews further indicated, family member delivered the medication and staff have been providing the medication to resident as prescribed and without interruption. Interview with R1’s family member (authorized representative) indicated, they brought R1 from the skilled nursing hospital to the facility with a five-day supply of medication. Family member stated, once R1’s pharmacy called family member to pick up the new medication order, it was picked up and promptly delivered to the facility and given to the med-tech staff to store and administer to R1. Family member stated, per their observations during their visits to R1, staff are providing R1 with all their medication as prescribed. LPA's review of resident’s LIC 622/Centrally Stored Medication and Destruction Record indicates, medication was started as of 5/15/25. Review of Medication Administration Record (MAR) for resident also indicates medications were administered as of 5/15/25. Review of resident’s file indicated resident was admitted to the facility on 5/14/25 from skilled nursing hospital. LPA reviewed R1's medication and found all medication prescribed to be present at the facility. Interviews with (10) out of (12) residents indicated, staff provide them with their medication as prescribed. Two (2) residents manage their own medication and therefore, do not get medication from facility staff. Medication and record review, interviews with staff, family member and residents do not corroborate the allegation.

Regarding: Facility staff do not provide adequate food service to resident in care.

It is alleged that staff have frequently failed to provide resident with meals and water and is often left hungry.

Interviews with (7) staff indicated, the kitchen provides food to all residents, daily, whether meals are served in the dining room or delivered to their room. Sufficient food is prepared for residents, and extra food is available for residents who wish to have additional portions.

****Continues on LIC 9099-C page 2

Regarding: Facility staff do not assist residents with clothing.

It is alleged that resident is unable to call for staff for assistance with diapering or getting dressed because her call button is not working, which leaves resident having to complete those tasks by themselves.

Interviews with (5) staff indicated, caregiving staff help residents when help is requested, with dressing, personal hygiene and other activities of daily living (ADLs). When assistance is warranted due to health impairments which limit resident’s ability to do things on their own, staff are available to provide care to residents. Staff stated, not only do they follow physician’s orders when providing care to residents per their abilities and limitations but also help in any way even when residents don’t have limitations. Staff are courteous and responsive to all residents.

***Continues on LIC 9099-C page 3

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.

It is alleged that resident is unable to call staff for assistance due to call bell now working.

LPA inspected (24) call buttons in (12) resident rooms. During inspection, (4) out of (24) call buttons were inoperable. When buttons were pressed on the call speakers, staff did not respond to the call made by LPA during testing for (4) call attempts. LPA conducted observation of the switchboard located in the main office which alerts staff of the calls made by residents and found that the (4) buttons located in the (2) resident rooms, did not trigger an alert. Front desk staff further indicated, they did not get an alert when the call button was pushed for those particular rooms. Interview with S1 indicated, when those call buttons were checked by maintenance staff, they observed that the internal wiring was malfunctioning. LPA tested R1's call button and observed it to be operable during visit. Interview with staff and LPA observations corroborate the allegation.

Based on LPA’s observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.