During today's visit LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:10 a.m. and throughout the visit LPA conducted one (1) in-person staff interview and obtained copies of pertinent documents relevant to the investigation.

On the allegation, Staff leave residents in soiled briefs/linins/clothes for an extended period of time, it is the concern of the Reporting Party (RP) that the facility staff left R1 sitting in soiled briefs for an extended period of time. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Interview with R1 revealed that during the time they lived at the facility March 2026 - May 2026, they received adequate care and supervision during the hours of 8 a.m. to around 5 p.m. During that time frame, staff would change their briefs regularly and checked on them periodically. During night hours, after 5 p.m. or so, staff were not as readily available as they were during morning and daytime hours. R1 stated that on multiple occasions they remained soiled during nighttime hours, and staff were unavailable even after multiple attempts calling for assistance.

Interview with facility caregiving staff revealed that they check residents’ briefs regularly, about every two hours or as needed or when requested. For residents who are alert and oriented, such as R1, they are able to verbalize to staff when they need to be changed. For residents who are not alert and oriented, staff will check on them about every two hours since they are not able to verbalize their needs. Staff stated they do not leave residents in soiled briefs for extended periods of time. Staff stated they regularly checked on R1 and ensured they were changed and not left soiled.

Interview with Resident #2 (R2) revealed that they have lived at the facility since May 2026, for about three (3) months and “love it here.” They stated the staff are very helpful and take good care of them. R2 stated that staff assist them regularly when needed and requested. R2 stated they have not been left in soiled briefs for an extended period of time and have not witnessed other residents being left in soiled briefs. Additionally, R2 stated that during meals all residents talk to one another, and no one has mentioned concerns or frustration regarding not being changed.

Report continued on LIC 9099-C PAGE 3...

Joint interview with Resident #3 (R3) and their Authorized Representative (AR-R3) revealed that R3 has lived at the facility for about 11 months and AR-R3 does not have any concerns. AR-R3 stated they serve as R3’s Power of Attorney (POA) and visit the facility daily at different times of the day. AR-R3 noted that due to cognitive decline, R3 is unable to answer any questions or provide accurate factual responses. AR-R3 stated that in all the times they have visited, R3 has not been left soiled or found soiled. AR-R3 noted that whenever assistance is needed, staff are available to help promptly.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff leave residents in soiled briefs/linins/clothes for an extended period of time is deemed unsubstantiated at this time.

On the allegation, Staff do not assist residents during the night, it is the concern of the Reporting Party (RP) that facility staff are not available during night hours, specifically from 5 p.m. to 8 a.m. To investigate this complaint, LPA conducted in-person interviews, telephonic interviews, file and record reviews, and obtained copies of pertinent documentation relevant to the investigation.

Records reviewed, including but not limited to the personnel report, staff schedule, and staff roster, revealed that the facility has two (2) caregivers scheduled from 7 a.m. to 7 p.m. and one (1) caregiver scheduled from 7 p.m. to 7 a.m., with a total of four (4) regular rotating staff.

Interview with R1 revealed that during the time they lived at the facility, staff would direct them back to their rooms after dinner. R1 noted that after 5 p.m. staff would have all residents return to their rooms and stated staff were then not available to them. R1 stated that on multiple occasions they called for staff assistance during night hours, however staff would not show up to help. R1 reported that on a few occasions they called for assistance using a bell provided by staff, but staff did not respond. R1 added that at one point they broke the bell due to how hard and how many times they rang it. Furthermore, R1 stated that on one or two occasions they called for staff assistance during the night and did not receive a response, resulting in them calling nearby family for assistance; however, the exact dates are unknown.

Report continued on LIC 9099-C PAGE 4...

Interview with Resident #2 (R2) revealed that they have lived at the facility for about three months and “love it here.” R2 stated they typically sleep through the night and do not usually require nighttime assistance; however, they believe and know that staff would assist if needed. R2 noted that on a few occasions—two or three, with exact dates and times unknown—when they needed assistance at night, staff were available and responded. R2 stated that during one of these occasions they were not feeling well and called for help, and staff assisted.

Joint interview with Resident #3 (R3) and their Authorized Representative (AR-R3) revealed that due to cognitive decline, R3 is unable to answer questions or provide accurate responses. AR-R3 stated they are rarely at the facility after 6 p.m. but noted they have observed staff to be available and assisting residents. Additionally, AR-R3 stated that R3 has been sleeping well at night and noted that in the past R3 would be up throughout the night but that is no longer occurring.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff do not assist residents during the night, is deemed unsubstantiated at this time.

On the allegation, Staff put residents in rooms at 5 PM it is the concern of the Reporting Party (RP) that facility staff force residents into their rooms after 5 p.m. To investigate this complaint, LPA conducted in-person interviews, telephonic interviews, file and record reviews, and obtained copies of pertinent documentation relevant to the investigation.

Records reviewed, including but not limited to the personnel report, staff schedule, and staff roster, revealed that the facility has two (2) caregivers scheduled from 7 a.m. to 7 p.m. and one (1) caregiver scheduled from 7 p.m. to 7 a.m., with a total of four (4) regular rotating staff.

Interview with R1 revealed that during the time they lived at the facility, staff would direct them back to their rooms after dinner. R1 noted that after 5 p.m. staff would have all residents return to their rooms, resident doors were shut, and residents were put to bed.

Report continued on LIC 9099-C PAGE 5...

Interview with Resident #2 (R2) revealed that from the time they have lived at the facility, they have roamed the living areas and their room at the times they choose. R2 stated they have never been asked to go to their room at a specific time nor have they been forced to leave the living areas at or around 5 p.m. R2 stated they have never witnessed staff forcing residents into their rooms at specific hours of the day and reported that they feel comfortable in the home. R2 stated that facility staff have never placed restrictions on their movement. R2 noted they spend most of their time in the living room and that staff do not direct them back to their room. Additionally, R2 stated staff encourage residents to comingle in the common areas rather than remain in their rooms.

Joint interview with Resident #3 (R3) and their Authorized Representative (AR-R3) revealed that due to cognitive decline, R3 is unable to answer questions or provide accurate responses. AR-R3 stated they are rarely at the facility after 6 p.m. but noted that during the times they have been present in the later hours, staff have been available and assisting residents, and they have not observed staff forcing residents into their rooms. AR-R3 stated that staff encourage residents to come to the common areas rather than remain in their rooms.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff put residents in rooms at 5 PM, is deemed unsubstantiated at this time.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was provided.