It is being alleged that R1 has been in care since 5/20/26 and that staff had barely completed the care plan on 6/19/26. On 7/28/26, LPA requested and received a copy of R1’s Preplacement Appraisal Information dated 3/9/26 and signed by S5, Director of Business Development. During interview with S1, Executive Director, on 7/28/26, needs of the residents are known immediately from the pre-assessments. LPA interviewed S5 on 7/28/26 and they stated, once a new resident alert is communicated, the resident’s care needs and dietary requirements are established and communicated to the care team. The Caregiver Supervisor is responsible for immediately informing and instructing staff regarding the residents’ care plan, including any scheduled physician appointments, as soon as notification is received.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 4 out of 5 denied the allegation and 1 was not sure. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 1 out of 5 denied the allegation and 4 were not sure.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not complete the residents pre-admission appraisal,” therefore, the allegation is unsubstantiated.

Allegation: Facility does not ensure sufficient staffing to meet the needs of residents in care.

It is being alleged that there is not enough staff to take the residents outside or to outings. Per interview with S2 on 8/5/26, there are 3 caregivers on schedule for the morning shift and 2 caregivers scheduled during the evening shift in Unit 1 to meet the residents’ service plan needs. In addition, there is a floater caregiver that is available to provide assistance when caregivers require additional support. Per interview with S2, when a caregiver is unavailable, staff frequently pick up additional shifts to ensure residents continue to receive needed services, including transportation assistance to scheduled medical appointments. Per interview with S3, Activity Director on 10/1/26, staff stated that they receive a list of residents who wish to participate in outside walks after permission has been obtained from the residents’ families or responsible parties. Brittany House does not own a company transportation van. However, caregivers are sometimes requested to accompany residents on walks outside the facility as appropriate to support their mobility and well-being. On 7/28/26 during interviews, LPA Shirley interviewed R3 and they stated that they enjoy walks down the street with the staff.

Con'd on 9099-C

It is being alleged that R1 developed a urinary tract infection (UTI) which progressed due to a delay in recognizing and addressing R1’s specific medical needs. On 8/5/26, LPA Shirley reviewed R1’s current service plan dated 6/19/26. LPA Shirley also reviewed the Resident Assessment for R1 dated 6/19/26. Per interview with S2, Caregiver Supervisor, R1 is checked and changed every 2 hours, which is also consistent with R1’s current service plan of full assistance with toileting needs. Per interview with S2 on 8/6/26, a (UTI) was not known about until they were informed by R1’s responsible party per doctor’s diagnosis. Per S2 staff placed water frequently in R1’s room, R1 had no changes in behavior, R1 never displayed any new or worse agitation, there was no note of R1 having frequent urination, R1 did not show signs of withdrawal and just recently R1 started participating in activities more since her admission. Per interview with S1, there was an in-service training for all staff on 5/20/26 regarding, “How to Identify Changes of Condition. LPA Shirley interviewed S8, Wellness Director on 10/1/26. Per S8, staff members participate in unit huddles every morning and S8 offers reminders of how to recognize signs of UTI.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not seek medical attention for resident in a timely manner,” therefore the allegation is unsubstantiated.

Allegation: Staff do not ensure resident’s toileting needs are being met

It was reported that a urine cup and dirty diapers were found in R1’s dresser drawer. There are concerns that this resident is not consistently receiving adequate assistance with diapering. Per interview on 7/28/26 with the Caregiver Supervisor S2, residents with incontinence care needs identified in their care plans are provided incontinence care and checked for changing at least every two hours, or more frequently as needed. S2 also stated that it is possible that R1 read the sign posted in her room stating, “Attention All Employees: Please do not dispose of soiled diapers in the bathroom trash cans.” Based on this, S2 believe the R1 may be changing their own pull-up and placing the soiled pull-up in the drawer instead of disposing of it appropriately. Per interviews with S1-S5 on 7/28/26, soiled diapers are disposed of in the trash bins.

con'd on 9099-C

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure resident’s toileting needs are being met,” therefore, the allegation is unsubstantiated.

Allegation: Staff do not ensure residents rooms are clean and sanitary

It is being alleged the dirty diapers were found on R1’s dresser drawer. Per interview with S1 and S2 on 7/28/26, the caregivers carry disposable trash bags with them as the change the residents. Caregivers dispose of diapers in the trash bags and the trash bags are then taken to the big trash bins. On 7/28/26, LPA Shirley reviewed the House Keeping, Laundry and Janitors schedule for June 2026. The Housekeeping schedule begins at 6:30am thru 3pm, Monday thru Friday. On 7/28/26, S6 stated that the schedule is the same for the weekends. Per interview on 7/28/26, S6 stated that all rooms are cleaned daily. On 7/28/26, LPA Shirley conducted a tour of this facility and went to R1’s room and observed that the room was clean.

Con'd on 9099-C

Allegation: Staff did not provide activities for residents

It is being alleged that there are not enough staff to take the residents outside or to outings which are advertised on Brittany House’s website. On 8/5/26, LPA Shirley reviewed Brittany House’s website in the section for Activities and Amenities offered. Based on the information available on the facility’s website, LPA Shirley did not observe any indication that residents are taken on community outings or off-site activities. Per review of facility’s plan of operation on 8/6/26 staff are not required to take residents outside or to go on outings. LPA Shirley reviewed Addendum “O” of the Admission Agreement and noted that families signed this waiver to allow the residents to go out of the facility on possible outings. The waiver indicates occasional outings and field trips but does not require staff to take residents on outings. Per interview with S1 on 7/28/26, Brittany House does not own a company van. While community outings are scheduled occasionally, the facility does offer a schedule of indoor activities to maintain engagement.

con'd on 9099-C

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not provide activities for residents,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Wellness Director, Manuel Mojarro.

It is being alleged that R1 missed their lab appointment on 6/22/26 because the staff fed R1 the morning of 6/22/26. On 8/5/26, LPA Shirley reviewed email dated 5/27/26 from a family member to the med tech room in Brittany House indicating R1’s medical appointment dates and instructions. On 6/4/26 the family member sent a follow-up email as they had not received confirmation that R1’s appointments were received and calendared for 6/22/26. Staff were instructed to allow R1 to fast the night before, meaning no food after midnight or in the AM until the lab work was complete. On 6/9/26, S7 responded to R1’s family member's email stating to rest assured that Brittany House staff were aware of upcoming appointments with instructions. S7 stated that they will reaffirm with staff once again. Per interview on 8/5/26, S7 stated they put R1’s appointment in the appointment book, prepared an appointment package consisting of a face sheet, all instructions, insurance information, medication information and all appointment information in the packet and they put the packet in the, Upcoming Appointments Scheduled bin. S7 stated that the morning of the resident’s appointments the packets are normally provided to the Caregiver Supervisor to ensure they accompany the resident to all scheduled medical appointments. Per interview with S2, Caregiver Supervisor on 8/5/26, the staff were aware of the R1’s scheduled medical appointment; however, the appointment was inadvertently overlooked. S2 further reported that the Executive Director was informed that R1 was inadvertently provided food by staff prior to R1’s scheduled laboratory appointment. As a result, R1 was not properly prepared for the scheduled laboratory appointment.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation and 1 did not know.

According to the information gathered there is sufficient evidence to support the allegation “Staff did not follow a resident’s doctors orders.” Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

Deficiencies are issued and an exit interview is conducted with the Wellness Director, Manuel Mojarro. A copy of this report and appeal rights were provided.