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32 | Allegation 2: Facility staff left resident in a soiled diaper overnight
Based on interviews, on 09/12/25, witness 1 (W1) reported that resident 2 (R2) stated, that resident 1 (R1) was left in a soiled brief for several hours, approximately 3 months prior. On 11/05/25, R2 reported one incident involving a soiled brief for R1, and this occurred approximately three months ago. On 01/14/26, staff 1 (S1) and staff 4 (S4) stated they had not observed R1 left in a soiled brief overnight. S4 reported that R1 was changed multiple times during night shifts.
Staff 3 (S3) stated residents are checked every two hours and, when possible, it was more frequently for R1, but stated that residents may delay activating their call pendant or decline assistance.
***Allegation 4: Facility staff did not ensure the kitchen is kept sanitary - transferred from LIC 9099C due to new information received*** On 11/05/25, Former ED/ADM stated that the maggots were seen in the garbage outside of the facility not inside the kitchen. This happened when there were delays when the garbage was not picked-up on time by the garbage truck. On 01/14/26 LPA interviewed resident 2 (R2) who stated that he/she was told by 2 staff (caregivers) that maggots were seen on the kitchen floor while they were taking the garbage out, R2 does not remember the names of the staff and did not see the maggots personally. On 5/5/26 LPA interviewed 2 kitchen staff (KS3 & KS4). KS3 & KS4 stated no other staff are allowed in the kitchen, except kitchen staff who cleans and take away the garbage. KS3 & KS4 did not observe maggots on the floor since they started working at the facility for over a year.***
Allegation 5: Facility staff did not deliver food in a timely manner
Based on interviews, on 09/12/25, W1 reported hearing concerns from R2 regarding meal delivery; however, no specific details or dates were provided. On 11/05/25, R2 reported one instance in which a meal delivery took more than one hour but could not recall the date. On 01/14/26, S3 recalled one similar incident but did not provide a specific date. S2 reported that typical food preparation and delivery time is approximately 15 to 20 minutes, with a 5 minute longer wait times for special orders, and stated that no complaints had been received.
Allegation 6: Facility does not have sufficient staff
Based on interviews and record reviews, 09/12/2025, W1 reported that the facility appeared disorganized but did not provide specific information regarding staffing levels. On 11/05/25, R2 reported high staff turnover. On 01/14/26, S1 and S4 stated staffing levels were sufficient. S3 stated that while response times may be delayed during high workload periods, required checks are conducted every two hours, with occasional delays of approximately 30 minutes. Based on record review of the facility's LIC 500 (Personnel Summary Report) the facility has adequate staffing and is in process of hiring more people.
Based on interview, document reviews and observation; although the allegations 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 allegations are unsubstantiated. No deficiencies were cited for the above allegations per CCR Title 22. An exit interview was conducted with ED/ADM Jolie Higgins and a copy of the report was provided.
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