Based on records review, it was confirmed that four out of five residents (R1, R2, R3 & R4) are non-ambulatory. The licensee provided three written statements from residents’ responsible parties as supporting evidence because residents in care won't be able to provide any statements due to their cognitive condition. Incidents received from R4’s responsible party dated 6/1/26, R5’s responsible parties dated 5/30/26, staff (S1 & S2). LPA obtained police records (case #26-0379) confirming that R1 was placed on 5150 holds due to mental health issues when they attacked a facility staff (S1) with a knife. On 3/30/26, LPA instructed the licensee to provide additional staffing to ensure the health and safety of the residents in care, but based on LIC500 Personnel Report dated 5/1/26, the licensee did not provide additional staffing to ensure the health and safety of the residents in care. LPA will address observation of R1 in case management due to licensee did not notify R1’s physician after observing a significant change of condition and documenting it in R1’s care plan dated 3/1/26. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.

Regarding allegation of licensee does not ensure resident is bathed. According to reporting parties, R1 apparently has not bathed in months and has dirty hair and body odor. Based on records review, R1’s physician report dated 6/18/25 indicates that R1 was able to perform all activities of daily living including bathing, dressing and grooming for themselves. R1’s care plan dated 3/1/26 instructs staff to observe R1 for cleanliness daily. Based on interviews conducted with staff (S1, S2 & S3) it was confirmed that R1 was independent to perform their activities of daily living, but after facility staff noticed that R1 was experiencing a decrease in their ability to care for their personal appearance by having dirty hair and body odor. Although the significant changes of R1’s mental condition were documented by the licensee who updated their care plan on 3/1/26, but the licensee did not send R1 for medical evaluation with their physician to obtain an updated physician report (LIC602) as stated in R1’s update care plan.

Continued into LIC9099C...

Although it was documented and observed by staff that R1’s hygiene care needs were increasing, staff did not assist R1 with bathing needs resulting in R1’s hygiene needs not being met. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.

An allegation about the licensee retains resident whose presence presents risk to the safety of other residents. Per reporting party, resident (R1) needs a higher level of care than this facility can provide and because of this it is a danger to themselves and to other residents. Co-complainant alleges that R1 should be relocated to a facility that is better suited to care for them and protect the other residents and staff. After an incident that occurred on 5/29/26 when R1 attacked facility employee with a cutting board, knife (case #26-0379) and was placed on a 5150 hold as a result of a mental health issue. At 9pmd on records review, an incident report submitted to the Department was found dated 3/30/26 notifying that on 3/21/26 at approximately 9pm caregiver heard R1’s roommate (R2) in distress, when the staff entered the room observed R1 trying to pull R2 out of their bed, struck the staff knocking them down. However, LPA instructed the licensee to provide additional staffing to ensure the health and safety of the residents in care, which it was not provided by the licensee as reviewed in the personnel report (LIC500) dated 5/1/26. On 4/1/26, the licensee submitted an unlawful 30-day eviction issued to R1 due to their behaviors that resulted in R1’s hospitalizations, but Licensee agreed to not proceed with eviction process, accepted R1 back to the facility and sent R1 again for medical evaluation if any further incidents happened. However, LPA instructed the licensee to provide additional staffing to ensure the health and safety of the residents in care, which it was not provided by the licensee as reviewed in the personnel report (LIC500) dated 5/1/26. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.

Although a printout from their physician indicates that R1 was prescribed Celexa 40mg one tablet every day for 90 days since 4/14/26, R1’s centrally stored medication and destruction records and medication administration record (MAR) indicate compliance with prescribed medication dates and dosages. Furthermore, daily medicine schedule confirming that R1 was taking citalopram 40 mg with breakfast and quetiapine medication marked as taken at bedtime. Based on interviews conducted with the Licensee, R1 was taking Seroquel 50mg at bedtime after increasing the medication from 25mg every six hours because that didn’t do anything to help to reduce R1’s aggressive behaviors. Based on interviews conducted with the licensee and staff (S1, S2 & S3), licensee is the designated person that pre pours medications to be given to the residents in care, which is a violation of Title 22 regulations. LPA will address a case management centrally stored medication management about transferring medications between containers. A finding that the complaint allegation of licensee mismanages residents’ medication is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Another allegation refers to licensee does not provide adequate care and supervision, resulting in resident eloping multiple times. Per Reporting party, R1 elopes from the facility three times a day and walks across the street through moving traffic, goes to an African dance event and takes off their clothing in public, and walks around town in underwear but no pants. Co-complainant stated that R1 would leave the facility on foot and walk through moving traffic. Based on records review, R1’s physician report dated 6/18/25 indicates that R1 was able to leave the facility unassisted, R1 walks long distances and has never become confused about how to return to their location. However, after incident that occurred on 3/21/26 where R1 was sent to the emergency room due to aggressive behavior towards another resident (R2), licensee updated R1’s care plan indicating that facility staff recommended to R1’s responsible party that R1 was not allowed to walk around town freely as it was not safe for R1 to do so, but an updated physician report was not requested by the licensee after observing a significant change of condition and care plan was not signed by R1’s responsible party. LPA will address observations relating to change of condition of R1 in case management. A finding that the complaint allegation licensee does not provide adequate care and supervision, resulting in resident eloping multiple times is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued on LIC9099C...

About allegation of licensee does not provide nighttime care to residents. The reporting party alleges that when incidents of R1 attempted to start fires at the facility there was no nighttime care in the facility, so if a resident needs help at night, they will not get it. On 7/21/26, LPA conducted 10-day visit to the facility, made observations, reviewed records and conducted interviews with residents and staff. Based on LPA’s observations on 7/21/26, LPA arrived at the facility approximately 8:47am, rang the bell as the morning shift was arriving too, but nobody came to open the door, arriving staff granted entry to the facility to LPA by the side door, LPA went around the facility, but no staff was present, licensee who resides in the back building arrived within five minutes, when LPA inquired about who was providing care and supervision to residents, licensee responded me, I worked the night shift, but I just went to the little house for a moment. Based on records review, an incident report submitted to the Department dated 3/30/26 confirms that there was a night staff present during incident that occurred on 3/21/26 at approximately 9pm when staff (S2) heard R1’s roommate (R2) in distress, when S2 entered the room observed R1 trying to pull R2 out of their bed, struck S2 knocking them down. Continues on LIC9099C...

Another allegation of licensee yells at residents. Per Reporting party and co-complainant stated that licensee often yells at residents that he is angry at them, especially R1. Based on LPA’s interviews conducted with staff (S1, S2 & S3) and residents (R2, R3 & R4) in care, LPA learned that there are no instances of licensee yelling at residents in care. Based on records review of residents’ physician reports and care plans indicate that two out of three residents (R2 & R3) have a diagnosis of dementia, but records review did not reveal any evidence to support above allegation. Although allegation is unsubstantiated, it was revealed through interviews with staff that staff (S1) has been observed speaking loudly to residents in care, but LPA was able/unable to obtain proof that S1 yells at residents in care? A finding that the complaint allegation of licensee yells at residents is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Last allegation of licensee does not prevent resident from eating spoiled food. The reporting party noticed that R1 has a refrigerator full of rotten, spoiled food that licensee does not prevent them from eating. Based on records review, there was no documentation of R1’s personal fridge located in their room, but according to interviews conducted by LPA with staff (S1, S2 & S3), R1 tended to eat only organic food items that they will obtain through food banks or on their own. Although R1’s care plan dated 3/1/26 instructs staff to observe R1 for food intake daily. Based on interviews conducted with staff (S1, S2 & S3) it was confirmed that R1 will maintain spoiled food items in their personal fridge without staff doing anything about it because they were scared that R1 could hit them, but it is unclear to determine based on verbal statements if facility staff have observed R1 eating spoiled food. A finding that the complaint allegation of licensee does not prevent resident from eating spoiled food is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.