The complaint alleged that the resident was physically attacked by another resident and called for help, but the staff did not take R1 to the hospital. On 10/24/2025, LPA Richard reviewed the interview records from the previous LPA Gardner with Resident #1 (R1). R1 was screaming that another resident slapped R1 and didn’t leave any marks, and no injuries, and R1 didn’t want to go to the hospital. On 10/24/2025, LPA Richard reviewed the interview records of the previous LPA with the Administrator (A1), who stated that after the incident occurred, staff notified the physician and moved the resident out of the area. On 10/24/2025, LPA Richard reviewed R1’s Physician Report LIC602A dated 06/17/2021, which showed that R1 has suffered from cognitive impairment. On 10/24/2025, LPA reviewed the interview records of the previous LPA Gardner with the Administrator, who stated that after the attack occurred, staff notified the physician and moved the resident out of the area. LPA Richard was unable to review any pertinent documents requested by the previous LPA Gardener. No residents were available for interview. Due to the facility being closed, no further information is available to LPA Richard. Therefore, the LPA was not able to complete a full investigation.

Based on the limited information gathered, LPA finds that although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; therefore, the allegation is Unsubstantiated.

Allegation #2: Staff did not respond to a resident’s alert.

The complaint alleged that R1 called for help, the resident came to assist, but there was no follow-up after the attack. On 10/24/2025, LPA Richard reviewed the interview record from the previous LPA Gardner with resident #1 (R1). There were no injuries, no marks, and R1 refused to go to the hospital. On 10/24/2025, LPA Richard reviewed the interview records of the previous LPA with the Administrator (A1), who stated that after the incident, staff notified the physician and moved the resident out of the area. LPA Richard was unable to review any pertinent documents requested by the previous LPA.

Report continued on LIC9099C

Based on the limited information gathered, LPA finds that although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; therefore, the allegation is Unsubstantiated.

Allegation #3: Staff mishandle a resident’s personal belongings.

The complaint alleged that the staff told R1 that R1's belongings were infested with bed bugs and that they placed them in the trash. On 10/24/2025, LPA Richard reviewed the interview records of the previous LPA, Gardner, with the Administrator (A1), who stated that R1 reported bed bugs in R1's room and bite marks. The facility throws away R1's mattresses, all bed linens, a blanket, and items belonging to R1, including colored pencils, books, and magazines; they all had bed bugs. All these were replaced with brand-new items. On 10/24/2025, LPA Richard reviewed R1’s Physician Report LIC602A dated 06/17/2021, which showed that R1 has suffered from cognitive impairment. LPA Richard was unable to review any of the relevant documents requested by the prior LPA, Gardner. No residents were available for interview. Due to the facility being closed, no further information is available to LPA Richard. As a result, the LPA was unable to complete a full investigation.

Based on the limited information gathered, LPA finds that although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; therefore, the allegation is Unsubstantiated.

Report Continued on LIC9099C

The complaint claimed that a resident's room (R1) had bed bugs. On October 24, 2025, LPA Richard reviewed the interview records from the previous LPA, Gardner, with the Administrator (A1). A1 stated that the facility staff treated all the rooms using over-the-counter chemicals purchased from Home Depot. Upon inspection the following day, February 18, 2022, staff discovered bed bugs in room 11 and are currently treating it, as well as room 12, which has new furniture. Records were reviewed from the interview with LPA Gardner, who also mentioned that the facility has been receiving pest control services from Truly Nolan Exterminator for the past three years.

On October 24, 2025, LPA Richard reviewed R1’s Physician Report (LIC602A) dated June 17, 2021, which indicated that R1 has cognitive impairment. LPA Richard was unable to access the documents requested by the previous LPA, Gardner. No residents were available for interviews. Due to the facility being closed, LPA Richard was unable to obtain any further information. Consequently, the LPA was unable to complete a full investigation.

Based on the limited information gathered, LPA finds that although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; therefore, the allegation is Unsubstantiated.

Allegations #5: Staff provide a resident with a soiled mattress while in care.

The complaint alleged that the facility provided R1 with a new mattress that was stained with urine and dirty. On October 24, 2025, LPA Richard reviewed the interview records from the previous LPA Gardner with the Administrator (A1). A1 stated that upon inspecting R1's room, staff discovered bed bugs in rooms 11 and 12, and they replaced the furniture in room 12 (R1) with new furniture, including a mattress wrapped in plastic. On October 24, 2025, LPA Richard reviewed R1’s Physician Report (LIC602A) dated June 17, 2021, which indicated that R1 has cognitive impairment.

Report Continued on LIC9099C

Based on the limited information gathered, LPA finds that although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; therefore, the allegation is Unsubstantiated.

Allegation #6: Residents are allowed to walk naked in the facility.

The complaint alleged that staff members permit residents to walk in the hallways naked. On October 24, 2025, LPA Richard reviewed R1’s Physician Report (LIC602A) dated June 17, 2021, which indicated that R1 has cognitive impairment. LPA Richard was unable to access the documents requested by the previous LPA Gardner. No residents were available for interviews. No staff or Administrator interview was conducted about the complaint allegation. Due to the facility being closed, LPA Richard was unable to obtain any further information. As a result, the LPA was unable to complete a full investigation.

Based on the limited information gathered, LPA finds that although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; therefore, the allegation is Unsubstantiated.

Allegation #7: Residents are allowed to harass other residents.

The complaint alleged that the facility allows residents to harass other residents in the hallways. On October 24, 2025, LPA Richard reviewed R1’s Physician Report (LIC602A) dated June 17, 2021, which indicated that R1 has a cognitive impairment.

Report Continued on LIC9099C

Based on the limited information gathered, LPA finds that although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; therefore, the allegation is Unsubstantiated.

This facility is closed on 05/08/2025.

No deficiencies cited.

A copy of the report will be mailed to the last known address: 23 Corporate Plaza Dr., Ste 150, Newport Beach, CA 92660.