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 LPA Shirey’s review of the shower schedule for Unit 1, where R1 resides and confirmed that R1 is scheduled to receive showers 3 times per week. This schedule is consistent with R1’s current service plan. 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.

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 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 the responsible person signed the Nature Walks, Outings, and Field Trips Waiver and Release of Liability on 5/20/26. 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 Executive Director, Esperanza Naaktgeboren.

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 Executive Director, Esperanza Naaktgeboren. A copy of this report and appeal rights were provided.