On January 25, 2026, an unannounced visit was conducted by Licensing Program Analyst (LPA) Pascua. During the visit, no signage was observed indicating a suspected outbreak or isolation precautions within the affected area of the facility.

Interviews with staff and management revealed the facility did not maintain or follow a definitive infection control protocol. Staff reported reliance on general infection prevention knowledge from trainings received years prior and not specific to facility policies. Facility management acknowledged they were unaware of which infection control procedures to implement and stated they had not been provided with guidance. In addition, facility staff were given a copy of the facilities infection control protocol and facility staff stated they have never seen the infection control protocol during their time at the facility. However, a review of the facilities LIC9282 EMERGENCY INFECTION CONTROL PLAN states that a review was conducted by the Facility Administrator on 09/30/2025.

Further interviews revealed the facility did not notify Local Public Health and Licensing of the suspected outbreak, citing the absence of a confirmed diagnosis. However, per the Facility Regional Nurse, infection control protocols are to be initiated immediately upon identification of suspected cases, and notification to Local Public Health and Licensing is required upon medical diagnosis. Additional interviews confirmed the facility did not implement infection control protocols until additional residents developed rashes.

Based on the information gathered, the facility did not follow infection control protocols.

As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

It was alleged that staff do not report a facility outbreak as required. During the investigation, it was determined that on December 30, 2025, facility staff identified two residents with red, itchy rashes. On January 8, 2026, an additional six residents residing in the same area of the facility were identified with similar symptoms. On that same date, the facility physician evaluated the affected residents, identified the condition as suspected scabies, and issued prescription treatment orders. On January 14, 2026, LPA Pascua received an email from the facility reporting a skin outbreak. However, subsequent interviews revealed that the facility had not reported the suspected cases to state licensing or local public health, as the cases had not been confirmed. Further interviews with facility management indicated they were unaware of the requirement to report suspected cases. A review of the facility’s Plan of Operation states that any suspected cases must be reported to local public health in accordance with Title 22 regulations.Based on the information gathered, the facility staff did not report a facility outbreak as required.

As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

Allegation: Emergency gate is locked

It was alleged that the emergency gate is locked. During the course of this investigation, the department conducted interviews and conducted a facility tour. Based on interviews conducted, it was admitted by the facility staff that the emergency gate was held by a pad lock and chain to prohibit the residents from leaving the facility. In addition, the facility staff stated that the Local Fire Department inspector did come to the facility and stated that they need to remove the lock on the gate and was not permitted to be locked. A tour of the facility was conducted which confirmed that there was a chain and lock on the facility gate. Based on the information gathered, the emergency gate was locked. As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

An immediate civil penalty was issued for Section 87203 Fire Safety. An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit.