An appraisal/needs and services plan for R1 dated 6/20/2025 does not mention any risks, non-risks or interest to R1 in leaving the facility unsupervised. A reappraisal dated 12/25/2025 states R1 is ambulatory and very independent; that all staff are to orient R1 to time, place and situation; and that all staff are to take R1 for a short walk. Staff interviews revealed that they do not think R1 is able to find their way back to the facility if they leave and the reason R1 needs to be oriented to time, place, and situation is because are confused at times. The Licensee states that R1’s primary care physician was made aware by family of the incident that happened on 9/12/2025, but that no staff notified the physician or requested an updated medical assessment. The Licensee states the physician has not been made aware of the incident that occurred in March 2026 and they do not know why they have not updated the appraisal/needs and services plan to reflect R1’s interest in leaving the facility unassisted and risk of elopement.

During the initial LPA visit on 3/11/2026 LPA requested the Licensee obtain an updated medical assessment from the physician and update R1's reappraisal. As of today's visit the Licensee has an updated medical assessment dated 4/30/2026 indicating that R1 is not able to leave the facility unsupervised and needs safety assistance. R1's reappraisal was updated with a date of 3/13/2026 stating staff are expected to increase visual checks of R1 and report increased wandering to the physician.

(Continued on LIC9099-C)

LPA reviewed an activity calendar dated March 2026 with most activities scheduled daily at 10,130, and 500, Licensee states these times are 10:00am, 1:30pm and 5:00pm. The general activities held at 10:00am are exercise or outdoor sitting; at 1:30pm movie or western show; at 5:00pm current events, ice cream social, or music; with ten days in March 2026 listing 11:00am pet therapy and five days with 1:30pm table games. During LPAs recent visits LPA has observed residents watching TV in the living room or spending time in their private rooms. Staff interviews reveal that they walk with R1 outside the facility once or twice a day and that R1 will sometimes play games like Scrabble with them or put together a puzzle. Staff stated R1’s family also takes them out of the facility multiple times each week and also walk around the neighborhood with them. Staff state pet therapy has not happened for months and that they have heard residents say they are bored. Resident interviews revealed that the facility does not provide activities, they are not aware there is an activity calendar, and have not seen a pet in the facility for pet therapy. Resident’s also state they are not allowed to go outside on the back patio and that staff do not do activities outside, like outdoor sitting. Residents state they are not encouraged to contribute to the planning of activities.

Based on observation, all interviews conducted, and documents obtained, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted, deficiencies cited on LIC809-D pages, report signed, appeal rights and report provided to Licensee.

On the allegation, staff are unable to communicate with residents due to a language barrier; it was alleged that most of the staff do not speak English and it’s very difficult for residents to communicate with them.

LPA noted there are two additional staff that work at this facility in addition to the Licensee. The primary language of these two staff is Visayan, a dialect in the Philippines. The Licensee also speaks the dialect. During recent visits, LPA observed staff were able to communicate in English sufficiently to complete tasks and respond to simple questions. At times, their responses were brief or required repetition, and there were moments when it was unclear whether they fully understood verbal instructions. However, staff consistently demonstrated understanding through their actions. Residents reported that they are able to communicate with staff with occasional difficulty understanding stating it could be due to their own hearing loss. LPA reviewed with the Licensee the personnel requirements in Title 22 stating staff are required to have training on the skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.

Based on observation, all interviews conducted, and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

This facility has two public restrooms. During LPA visit on 3/11/2026 and today Licensee showed LPA a supply of paper towels and toilet paper kept at the facility, both bathrooms had paper supplies and LPA did not note a urine smell during either visit. During a recent visit LPA noted the paper towel dispenser in the public bathroom closest to the resident bedrooms to be located high up on the wall and asked that it be moved lower for easier access. The Licensee has since moved the dispenser lower. Residents state they cannot think of a time when there were no paper products, maybe a small quantity once, and they have not noted strong urine smells in the facility.

Based on observation, all interviews conducted, and documents obtained, at this time the above allegations were found to be unsubstantiated, meaning that the allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred.

On the allegation, staff do not ensure resident's hygiene needs are being met; it was alleged that sometime in November 2025 R1 was wearing dirty clothes, smelled, and their hair looked greasy and dirty.

R1’s medical assessment states that they do not require assistance to bath, dress and groom. Staff state the residents bath 1-2 times a week and if they want to more often they can. Staff state R1 is able to dress independently but they usually assist with that task, as well as, bathing because they do not want R1 to fall and R1 has mobility limitations. They state R1 does get frustrated sometimes and try to refuse their help. Residents state staff assist them with bathing and grooming if they need it.

Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Review of R1’s records reveal they are prescribed insulin injections; the medical assessment dated 6/11/2025 states that R1 is able to administer their own injections, is prescribed a diabetic/low carb diet, and the appraisal/needs and services plan dated 12/25/2025 states R1 is able to self-administer their insulin injections. R1 has a continuous glucose meter that continuously checks their blood glucose level, with external display that has an audible alert when their insulin is outside the designated range. Interviews revealed one of R1’s local family members is a nurse who assists R1 in replacing the sensor every 15 days.

During two separate visits, including the visit on 3/11/2026, LPA observed R1 self-administer their injections. R1 states the food served at the facility follows their diet. Staff state and record review reveal R1 is on a diabetic/low carb diet and they do provide foods that meet R1’s needs. Staff stated due to tremors they sometimes assist by stabilizing R1’s hand as R1 administers the insulin, they also assist R1 by preparing the insulin pen with needle, and set the insulin pen dial per physician order. The Licensee was able to provide documented staff training on diabetes.

As of today's visit the California Board of Registered Nursing (BRN) shows the Licensee/Administrator of this facility has a registered nursing license with a status of “retired”, as of 12/31/2023. According to the BRN website, a retired status means the registered nurse (RN) shall not engage in the practice of nursing. Meaning the Licensee/Administrator is not allowed to administer injections to R1, or any resident, per California Title 22 regulations for residential care facilities for the elderly. Additionally, any other staff at this facility who are not appropriately skilled professionals may not administer injections. Licensee states they recently paid to bring their RN license current.

Based on observation, all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted, report signed, and report provided to the Licensee.