It was alleged that staff threatened resident. This investigation consisted of facility observations, interview with staff and resident. On 5/15/2025 LPA Pang Lee conducted a facility visit and observed facility staff assisting residents. On 6/17/2025 LPA Shakaricka Hughes conducted a follow-up facility visit and observed facility staff assisting residents. Additionally, interview with 3 out of 4 residents revealed that staff has not been observed threatening residents in care. Interview with facility care staff revealed that allegations of staff threatening residents were denied. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

Staff does not ensure residents showering needs are being met.

It was alleged that staff does not ensure resident’s showering needs are being met. This investigation consisted of interview with staff and residents, and facility observation and records review. On 5/15/2025 LPA Pang Lee conducted a facility visit, interview with residents indicated no concerns and stated they are content with their current showering and hygiene needs and care. On 6/17/2025 LPA Shakaricka Hughes conducted a follow-up facility visit, interview with residents in care reflected no concerns with showering or hygiene needs. Interview with facility staff revealed that residents are showered regularly. LPA Hughes observed residents in good hygiene and presented with no evidence of soiling. Records review of Physician’s report LIC 602A indicated that 3 out of 5 residents do not require assistance with bathing and or showering. Review of resident showering schedule indicates that residents are on a weekly schedule which includes multiple showers per week. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

Continuation 9099-C

It was alleged that staff does not safeguard resident's personal belongings. This investigation consisted of interview with staff and residents, and facility observation. On 6/17/2025 LPA Shakaricka Hughes conducted a follow-up visit to the facility, interview with residents indicated that there is no concern with safety of residents personal belongings. Interview with facility staff indicated that residents in care has not expressed concerns about personal belongings not being safe within the facility. On 7/2/2025 LPA Hughes conducted a facility visit, interview with facility staff revealed there has not been concerns with residents personal belongings not being protected. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

It was alleged that staff does not ensure resident’s dietary needs are met. This investigation consisted of facility observation, records review and interview with staff and residents. On 5/15/2025 during a tour of the facility, LPA Lee observed 2-day perishables and 7-day non-perishable food supply. The 2-day perishable food supply contained, fresh fruits and vegetables, water and other food supplies. Additionally, a review of the facilities program plan states that residents with special dietary request and needs will be accommodated. Resident file review of Appraisal/ Needs and Services LIC 625 indicated that 3 out of 5 residents have a modified low salt diet. Review of residents Physician’s report LIC 602A indicated that that 3 out of 5 residents do not require a specific diet. Resident interview reflected that 4 out of 5 residents have no concern with their dietary needs not being met at the facility. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

Allegation: Staff does not ensure resident's hygiene needs are met

It was alleged that staff does not ensure resident’s hygiene needs are being met. This investigation consisted of interview with staff and residents, facility observation, and records review. On 6/17/2025 LPA Shakaricka Hughes conducted a follow-up facility visit. Interview with residents reflected that there is no concern with hygiene needs not being met. Interview with staff revealed that residents’ hygiene needs are being met, LPA Hughes observed individual resident hygiene containers located in the garage area, with adequate hygiene items. Records review of resident showering schedule shows residents scheduled for showering throughout the week. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

Allegation: Staff does not ensure resident has adequate clothing.

It was alleged that staff does not ensure resident has adequate clothing. This investigation consisted of interview with staff and residents, and facility observation. On 5/15/2025 LPA Pang Lee conducted a facility visit, interview with residents in care reflected that residents have adequate clothing. Interview with facility staff reflected that the facility is not responsible for providing clothing for the residents in care. On 6/17/2025 LPA Hughes conducted a follow-up facility visit and observed clothing in the dresser drawers of 5 out 5 residents in care. Based on the information obtained, there is no evidence to support the allegation, therefore it could not be corroborated at this time.

Continuation 9099-C

It was alleged that staff does not provide activities to residents. This investigation consisted of records review, facility observations, and resident interviews. On 6/11/2025 LPA Hughes reviewed facility program design, and it was stated within the program design that: Residents would be offered a wide variety of fun and stimulating activities which are appropriate for cognitive and physical activities for the resident. On 5/15/2025 LPA Lee observed residents’ activities in the facility, Resident 1 (R1) was initially seen sleeping in the common area and was later transported to an appointment. Resident 2 (R2) was seated at the dining table, having coffee and eating breakfast. Resident 3 (R3) was lying on their bed in their room. Resident 4 (R4) was walking through the hallway toward the common area. Resident 5 (R5) was in their room, lying in bed and watching TV. On 6/17/2025 LPA Hughes, conducted interviews with 4 out of 5 residents, and concluded that no activities are being provided in the facility. This was observed as not in compliance with Title 22 regulation 87219(a)(1) Planned activities. Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Aisake Ratu and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.