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On January 20, 2026, LPA visited the facility from 12:20 PM to 4:25 PM to commence the investigation. LPA requested records, toured the facility, and interviewed staff, residents, and residents’ family members. The staff interviewed (S1, S3, S4, S5, and S6) could not confirm the incidents described by RP. LPA later interviewed S2, who also did not corroborate the allegations.
LPA interviewed Resident 4 (R4) and an outside source (OS1), who typically visited the facility Monday through Friday from 1:00 PM to 3:00 PM, and occasionally on Saturdays to see resident 4 (R4). OS1 stated they were satisfied with both the facility and the staff, and had never observed any incidents related to the allegations. OS1 also stated that staff primarily communicate through walkie talkies rather than cell phones, and use those devices to coordinate resident care. OS1 reported never seeing a resident wait longer than five minutes for assistance.
LPA toured the facility and entered eleven randomly selected rooms on both floors. No unkept rooms or soiled residents were observed. LPA also checked for double diapering or staff on their phones, and did not find evidence supporting the allegation.
LPA attempted to contact R1’s spouse (OS2) by phone several times between January 20, 22 and 26 on, but received no answer. OS2 later responded by text message, stating they did not make the complaint and that RP had made the allegations. OS2 asked LPA to speak directly with RP, and did not respond to any further calls or messages.
LPA contacted RP on March 13th, 2026, to report that witnesses did not corroborate the allegations and that no similar incidents were observed during the visit. RP claimed to have photographs and sent them to LPA on two separate occasions. LPA informed RP that the photographs lacked sufficient context, as it was not possible to determine how long the residents waited or whether the photos were taken at the facility. LPA agreed to conduct an additional visit to determine whether these incidents were occurring.
On July 7, 2026, LPA conducted an additional visit after 2:30 PM and met with R1 while touring the facility. R1 appeared clean, comfortable, and responsive, sitting in the common area reading a magazine. LPA observed residents and staff in the common area and did not witness any incidents similar to the allegations. LPA further observed staff working in coordinated teams, communicating resident needs, and assisting residents to their rooms for clothing changes as necessary.
Based on interviews, record review, and LPA observations, the preponderance of evidence standard was not met. Therefore, the allegation is unsubstantiated. No deficiencies were cited in accordance with Title 22 of the California Code of Regulations.
Report and Appeal Rights were discussed with and provided to the Health Services Director Leah Adolfo. The signature below confirms receipt. |