On 06/30/2026 LPA Mosley conducted the initial 10-day visit, 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. Throughout the visit LPA conducted interviews with the DRS, ED and facility designee, along with a file review for Resident #1 (R1) and obtained copies of pertinent documents relevant to the investigation.

On 07/09/2026 LPA Mosley conducted a subsequent visit, 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 Mosley conducted twelve (12) interviews, three (3) staff and nine (9) residents and obtained copies of pertinent documents relevant to the investigation.

During today's visit LPA and staff 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 and obtained copies of pertinent documents relevant to the investigation.

On the allegation, Staff placed resident on hospice care without required diagnosis from a qualified physician it is the concern of the Reporting Party (RP) that Resident #1 (R1) was placed on hospice without required diagnosis from a qualified physician. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, file and record review for R1 and obtained copies of pertinent documentation relevant to the investigation.

LPA reviewed R1’s records including but not limited to hospice records, care plan, physician report and hospital records. Record review revealed that R1 was placed on hospice on 12/23/2025 and the election of hospice care benefits was approved by family on 12/23/2025 and by a licensed physician. On 07/09/2026 at 4:20 p.m. LPA conducted a medical board of California search for the physician listed on R1 hospice paperwork and found the physicians license to be active as of 03/30/2006 with the expiration date of 06/30/2027. On R1’s hospice paperwork lists cerebral infraction, unspecified with the effective date of 12/21/2025 to 03/20/2026. 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 placed resident on hospice care without required diagnosis from a qualified physician is deemed unsubstantiated at this time. Report continued on LIC 9099-C PAGE 3...

On the allegation, Staff do not safeguard resident's cash resources it is the concern of the Reporting Party (RP) that Resident #1 (R1) had lost $150 dollars, or someone may have taken their money. To investigate this complaint, LPA conducted telephonic interviews, in person interviews, a file and record review and obtained copies of pertinent documentation relevant to the investigation.

Interview with R1 revealed that sometime last month, on an unknown date, they had misplaced approximately $100. R1 stated that they reported the incident to the receptionist, who then had a staff assistant search for the money. R1 explained that the money was later found in their jacket pocket. R1 additionally stated, “At 89 and 90, you are not as sharp as you used to be.”

Resident interviews indicated no concerns regarding the safeguarding of their property during their stay at the community. Residents reported no issues with the protection of their cash resources or personal belongings. Furthermore, residents did not express any additional concerns.

Staff interviews revealed that when residents report personal belongings, including money, as missing, staff initially conduct a search with the residents to determine whether the items can be located. Staff stated that in the majority of cases—approximately 99%—the items are found. The incident is documented, and facility protocol is followed. Additionally, staff reported, “It has been a long time since something has gone missing or been reported missing and not found.”

Records review, including but not limited to the admission agreement, theft and loss policy, and Client/Resident Personal Property and Valuables (LIC 621), indicated that R1 did not list any valuables, including money. 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 safeguard resident's cash resources is deemed unsubstantiated at this time.

On the allegation, Staff did not inform resident's responsible party of resident's change in condition and Staff did not obtain medical care for resident in a timely manner it is the concern of the Reporting Party (RP) that Resident #1 (R1) was experiencing cognitive impairment, and the facility staff did not notify the family or get them the proper medical care timely. To investigate this complaint, LPA conducted telephonic interviews in person interviews, a file and record review and obtained copies of pertinent documentation relevant to the investigation. Report continued on LIC 9099-C PAGE 4...

Interview with R1 revealed that they were not regularly monitoring their health, stating, “I am not on top of my health and did not check on it regularly.” R1 reported that while on hospice, they received their medications but felt as though their condition was not being actively monitored. R1 stated that they began feeling unlike themselves and experienced episodes of confusion, which they reported to staff. R1 added, “The nurse told me to go to the hospital, but I initially refused and fought it.”

On 06/14/2026, R1 was out of the community with family and continued to feel confused and not like themselves. On 06/15/2026, R1 informed facility staff that they had hit their head. Staff contacted 911, and R1 was transported to the hospital. R1 stated they are fully independent, make their own decisions, and serve as their own responsible person.

Interview with staff revealed that R1 had been encouraged on multiple occasions to go to the hospital due to observed cognitive concerns; however, R1 declined each time. Staff stated that R1 is independent and serves as their own responsible person, making their own decisions. Staff reported, “All we can do is encourage our residents to go to the hospital. If they choose not to go, that is their right.” Staff further indicated that once R1 was transported out of the community, the facility contacted R1’s family to inform them of the transfer to the hospital.

Record review revealed that the facility submitted an incident report dated 06/15/2026 for R1, documenting that R1 had hit their head and, with staff encouragement, was transported to the hospital for evaluation. R1’s family was notified. The Department received the incident report on 06/19/2026, which is within the required reporting timeframe. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur. Therefore, the allegations of Staff did not inform resident's responsible party of resident's change in condition and Staff did not obtain medical care for resident in a timely manner are deemed unsubstantiated at this time.

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