Inspection Reports for Kingsley Manor

The visit was a 24-hour Case Management incident visit conducted due to an allegation by resident 1 (R1) that staff 1 (S1) inappropriately touched R1 on 2025-09-07.

Licensing Program Analysts conducted a physical plant tour and did not observe any health and safety risks to residents. Records for resident 1 and staff 1 were reviewed, and R1 was interviewed regarding the allegation.

Resident 1 alleged that staff 1 inappropriately touched them on 2025-09-07. Licensing Program Analysts interviewed resident 1 and reviewed relevant records. No deficiencies or severity levels were documented in the report.

An unannounced required 1-year inspection was conducted to evaluate compliance with licensing requirements and assess the facility's operations, infection control, safety, staffing, and resident care.

The facility was found to be in compliance with all licensing requirements with no deficiencies cited. Infection control practices, safety measures, staffing, food service, and resident care were all observed to meet regulatory standards. A technical violation was issued.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was charging a resident for services not rendered.

The investigation found that the resident was receiving the services identified by a re-assessment to prevent eloping, and that seven out of eight residents denied the allegation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility charged a resident for additional services without informing or obtaining consent from the resident's responsible party, and that the additional fee was not listed in the admission agreement. The investigation included interviews, document reviews, and observations, concluding the allegation was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by complaints alleging inadequate care and supervision, failure to conduct reassessment, retaliation against a resident, and unlawful eviction.

Two allegations were substantiated: staff did not provide adequate care and supervision to Resident R1, including failure to check blood pressure and conduct room checks, and staff did not conduct a reassessment of Resident R1 while in care. Two allegations were unsubstantiated: staff retaliating against a resident and unlawfully evicting a resident. Deficiencies were cited under California Code of Regulations, Title 22.

The complaint investigation was substantiated for allegations that staff did not provide adequate care and supervision and failed to conduct reassessment for Resident R1. The allegations of staff retaliation and unlawful eviction were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not meeting residents' food service needs and that staff were harassing a resident.

The allegation regarding food service needs was substantiated, finding that staff did not promote resident independence by not allowing residents to open their own cereal boxes, which was corrected by the facility. The allegation of staff harassing a resident was unsubstantiated due to lack of sufficient evidence.

The complaint investigation was substantiated for the allegation that staff were not meeting residents' food service needs, specifically regarding residents not being allowed to open their own cereal boxes. The allegation that staff were harassing a resident was unsubstantiated.

An unannounced complaint investigation visit was conducted on 02/25/2025 regarding allegations of staff negligence leading to resident's property damage and staff not following infection control guidelines.

The investigation found insufficient evidence to substantiate the allegations. Staff and most residents denied the claims, and observations showed staff following infection control practices. Therefore, both allegations were unsubstantiated and no violations were cited.

The complaint investigation was unsubstantiated. Allegations included staff negligence causing damage to a resident's denture container and failure to follow infection control guidelines. Interviews and observations did not provide a preponderance of evidence to prove the allegations.

The visit was a Case Management inspection stemming from an initial complaint investigation conducted on 02/25/2025 regarding facility policies on residents bringing outside food into the dining room.

One Type B violation was cited for violation of personal rights section 87468.2(a)(3) due to staff prohibiting residents from bringing outside food into the dining room without staff approval. A $250 civil penalty was assessed for repeat violations within a 12-month period.

The visit was triggered by an initial complaint investigation. The violation was substantiated and a repeat civil penalty was assessed.

The visit was a Case Management - Incident unannounced inspection conducted to investigate an unusual incident report involving a former resident who was allegedly force fed by a private caregiver prior to passing away.

The Licensing Program Analyst conducted a health and safety check and interviews with staff and family members. No signs of neglect, abuse, or immediate health and safety threats were observed during the visit.

An unannounced complaint investigation visit was conducted regarding allegations that staff were illegally evicting a resident and confiscating the resident's belongings.

The investigation found insufficient evidence to substantiate the allegations. Staff and residents interviewed denied the allegations, and no deficiencies were cited.

The complaint involved allegations that staff illegally evicted a resident and confiscated the resident's walker. The investigation was unsubstantiated due to lack of preponderance of evidence.

The visit was a Case Management - Deficiencies inspection conducted on 10/01/2024, stemming from a subsequent complaint investigation conducted on the same date.

One Type B violation was cited related to a resident's personal rights, specifically regarding the resident's right to smoke away from the facility, which was found to be within their rights as a citizen.

The visit was triggered by a complaint investigation. The violation was substantiated as a Type B violation for personal rights.

An unannounced case-management incident visit was conducted in response to a Special Incident Report submitted by the facility regarding a resident's report of fear and agitation involving staff.

The investigation found that staff member S2, who was no longer employed at the facility, grabbed a resident's arm in an elevator, posing an immediate personal rights risk. No other health and safety concerns were observed during the visit.

The visit was complaint-related based on a Special Incident Report submitted on 08/01/2024. The complaint involved Resident #2 being afraid of staff member S2, who was found to have grabbed the resident's arm. The complaint resulted in a citation being issued.

An unannounced complaint investigation was conducted in response to allegations received on 2024-07-29 regarding improper resident positioning, unmet toileting needs, and development of pressure injuries at Kingsley Manor.

The investigation found no corroboration for the allegations after interviews with residents and staff, record reviews, and observations. Staff were found to assist residents appropriately, and no pressure injuries were identified. The allegations were determined to be unsubstantiated due to lack of evidence.

The complaint investigation was unsubstantiated. Allegations included staff not properly positioning a resident, not meeting toileting needs, and a resident developing pressure injuries. Interviews with eight residents and staff, as well as record reviews, did not support these claims.

The inspection was an unannounced required 1-year visit to evaluate compliance with care and regulatory standards using the full Care Compliance and Regulatory Enforcement (CARE) Tools.

The facility was found to be in compliance with no deficiencies observed. The inspection covered multiple domains including infection control, physical plant safety, staffing, personnel records, client rights, food service, and disaster preparedness. Fire clearance was approved and emergency drills were up to date.

The inspection was an unannounced complaint investigation visit to investigate an allegation of unlawful eviction of a resident who was not allowed to return to the facility after hospital discharge.

The allegation of unlawful eviction was substantiated. The facility staff refused to accept Resident #1 back after discharge on 06/18/2024 without providing a 30-day eviction notice, and there was no documentation indicating the resident required a higher level of care.

The complaint alleged unlawful eviction of Resident #1 who was not allowed to return after hospital discharge on 06/18/2024. The investigation found the allegation substantiated based on interviews and document review.

The visit was a case management follow-up to issue a deficiency after an incident involving the death of Resident #1 on 10/3/23, which was investigated by the Department of Social Services Investigation Branch.

The investigation found that staff failed to provide proper supervision to Resident #1, who was found injured after a fall and later died. Staff were neglectful in checking on the resident during their shifts, and one staff member had a history of misconduct including sleeping on the job.

The complaint investigation was substantiated based on the neglectful actions of Staff #1 and Staff #2 towards Resident #1, which led to the resident's injury and subsequent death.

The inspection was an unannounced complaint investigation visit triggered by an allegation of questionable death of a resident.

The investigation found that two staff members failed to provide supervision to Resident #1 during their shifts, resulting in the resident falling and sustaining injuries. However, there was no evidence to establish a causal link between the failure to conduct timely rounds and the resident's death, which was ruled an accident by the Medical Examiner. The allegation was determined to be unsubstantiated.

The complaint alleged that Resident #1's death was caused by neglect from Staff #1 who did not check on the resident during the overnight shift. Interviews and record reviews showed staff failed to provide supervision, but no causal link to death was found. The allegation was unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-02-27 regarding staff behavior and facility conditions at Kingsley Manor.

The investigation included interviews with staff and residents, a tour of the facility, and document reviews. All allegations, including staff not keeping the facility free of obstructions, inappropriate speech, lack of respect and dignity, and failure to safeguard resident property, were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations that facility staff did not keep the facility free of obstructions, spoke inappropriately to residents, did not treat residents with respect and dignity, and failed to safeguard resident property. After investigation, all allegations were determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 06/13/2022 concerning staff misconduct and resident care issues at Kingsley Manor.

The investigation found most allegations unsubstantiated due to lack of evidence or contradictory statements, except for the allegation that staff did not respond timely to residents' call buttons, which was substantiated due to issues with the facility's pager system causing delayed responses.

The complaint investigation addressed ten allegations including staff pushing a resident causing a fall, staff threatening residents, staff under the influence of illegal substances, lack of dignity and respect towards residents, resident-to-resident injury, staff breaking resident belongings, unlawful eviction, missing personal belongings, inappropriate staff comments, and delayed staff assistance. All allegations except the delayed response to call buttons were found unsubstantiated.

The inspection was conducted as an unannounced complaint investigation regarding allegations that facility staff were interfering with the resident council.

The investigation found no evidence that the facility was interfering with the resident council. The issue was related to a corporate policy change on how the Employee Appreciation Fund is handled, which residents and staff were notified about. The allegation was unsubstantiated.

The complaint alleged that facility staff were interfering with the resident council by changing the policy on distribution of the employee appreciation fund. The investigation included interviews with residents, staff, and corporate representatives. The allegation was found to be unsubstantiated due to lack of evidence.

The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not meeting resident's needs, not safeguarding resident's personal belongings, and harassing a resident.

The investigation substantiated that staff failed to follow medication management procedures and did not properly care for a resident's diabetic foot wound, posing health and safety risks. However, allegations that staff stole resident belongings and harassed the resident were found to be unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for the allegation that staff were not meeting resident's needs, specifically medication management and wound care. The allegations that staff did not safeguard resident's personal belongings and that staff harassed the resident were unsubstantiated due to lack of sufficient evidence.

The inspection visit was conducted as a complaint investigation to review significant changes made by the facility in its policy and plan of operation, specifically regarding the acceptance and handling of 'tips' from the resident's council for the employee appreciation fund.

The facility made a significant policy change to accept 'tips' from the resident's council for employee appreciation funds, distributing these via payroll and taxing them, without notifying the licensing agency or updating the plan of operation to explain how resident monies would be safeguarded. A deficiency was cited for failure to maintain an updated plan of operation including safeguards for resident cash.

The visit was complaint-related, investigating the facility's policy change regarding employee appreciation funds. The deficiency was substantiated and cited under section 809D.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-06-11 regarding allegations of medication mismanagement and lack of dignity and respect towards residents.

The investigation substantiated the allegation that facility staff mismanaged resident #1's medication, specifically that a medication pill belonging to another resident was dropped in resident #1's room and left there, posing a health and safety risk. The allegation that staff did not treat residents with dignity and respect was unsubstantiated due to lack of sufficient evidence.

The complaint involved allegations that facility staff mismanaged resident's medication and did not treat residents with dignity and respect. The medication mismanagement allegation was substantiated, while the dignity and respect allegation was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility would not accept monthly rent payments from a resident when the resident attempted to pay monthly rent.

The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated. Staff interviews and document reviews confirmed an eviction notice and unlawful detainer were issued, and the facility was legally advised not to accept payments from the resident.

The complaint alleged that the facility would not accept monthly rent payments from a resident. The allegation was unsubstantiated after investigation. It was confirmed that an eviction notice and unlawful detainer were issued to the resident, and the facility was legally advised not to accept payments. The resident wanted the facility to obtain payment from the Assisted Living Waiver program, but that program does not cover rent or board and care fees.

This is a follow up annual visit to continue the annual inspection that was first conducted on 7/11/2023.

Personnel records and staff training were reviewed and found to be in compliance, including criminal background clearance and required certifications. Health-related services such as medication administration were properly managed, and disaster preparedness measures including emergency plans and drills were observed.

An unannounced Required 1 Year annual inspection visit was conducted using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with regulatory requirements.

The inspection covered 12 CARE tool domains including infection control, physical plant safety, staffing, personnel records, resident rights, food service, and incident reports. A deficiency was found related to water temperature in two restrooms exceeding the allowed range, which was corrected during the visit. The annual inspection was not completed and will be resumed at a later date.

The visit was an unannounced complaint investigation triggered by an allegation that staff were not preventing a resident from being financially abused by another resident.

The investigation found insufficient evidence to substantiate the allegation of financial abuse between residents. Interviews with residents, staff, and family members, as well as document reviews, indicated that the alleged financial transfer had not occurred and the resident denied abuse. The allegation was determined to be unsubstantiated.

The complaint alleged that resident (R1) was being financially exploited by resident (R2), who requested a transfer of stock shares owned by R1. The investigation included interviews with 16 residents, 4 staff, private caregiver, and family members, as well as review of resident files and physician reports. Resident (R1) denied abuse and was oriented to person, place, and situation. Resident (R2) denied abuse and stated the transfer was a mutual decision. No financial interests had been transferred due to lack of authorization. The allegation was unsubstantiated due to insufficient evidence.

An unannounced complaint investigation was conducted regarding an allegation that staff were not following a resident's dietary needs.

The investigation found that residents and staff reported no ongoing issues with dietary needs. The facility provides special menus and replacement meals as needed. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged staff were not following a resident's dietary needs. After interviews with residents and staff, and a tour of the kitchen and dining areas, the allegation was found unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to allegations received on 04/10/2023 regarding staff behavior and resident care at Kingsley Manor.

The investigation found that staff communicated politely and professionally with residents, treated residents with dignity and respect, and provided a comfortable environment. Interviews with residents and staff did not substantiate the allegations.

The complaint involved allegations that staff spoke inappropriately to residents, failed to treat residents with dignity and respect, and failed to provide a comfortable environment. The investigation was unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation was conducted regarding an allegation that the facility was financially abusing a resident while in care.

The investigation included interviews with the resident, staff, and administrator, as well as a review of relevant documents. It was found that the resident spent his own money gambling and the facility did not have access to his funds. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged financial abuse of a resident. The Power of Attorney reported withdrawals over $1250 in two months, but stated the facility did not do any wrongdoing. The resident confirmed the facility did not touch his money and spends money at casinos. The allegation was unsubstantiated.

The inspection was an unannounced complaint investigation triggered by allegations that the facility elevators were in disrepair and that the facility did not have heat.

The investigation substantiated that one elevator in the Leitzell Hall building was down for a couple of months but has since been repaired and is now working properly. The allegation regarding lack of heat was unsubstantiated as the facility's heating system was found to be functioning properly with residents reporting comfortable room temperatures.

The complaint investigation was substantiated for the elevator disrepair allegation and unsubstantiated for the heating allegation. The elevator was down due to difficulty obtaining parts but was repaired prior to the inspection. The heating system was functioning properly with maintenance staff monitoring circuit breakers and residents reporting adequate heat.

The inspection was an unannounced complaint investigation visit triggered by allegations including a resident sustaining an injury while in care, a resident threatening the safety of others, and staff not meeting qualifications for their job duties.

The investigation found insufficient evidence to substantiate the allegations. The resident injury allegation was unsubstantiated despite documentation of a fall and hospitalization. The allegation of a resident threatening others was unsubstantiated after review of incident reports and resident removal. The allegation that staff did not meet qualifications was also unsubstantiated based on interviews and training documentation.

The complaint investigation was unsubstantiated. Allegations included a resident injury from a fall, a resident exhibiting threatening behavior and intoxication, and staff performing duties without proper qualifications. Investigators reviewed incident reports, interviewed staff and residents, and reviewed training and physician reports. No preponderance of evidence was found to prove violations.

The inspection was an unannounced complaint investigation visit regarding allegations that the facility had bed bugs, was not clean and sanitary at all times, resident rooms were malodorous, and the facility was not meeting residents' dietary needs.

The investigation substantiated the allegation of bed bugs in several rooms based on observations, resident and staff interviews, and pest control reports. The allegations regarding cleanliness, odors, and dietary needs were found to be unsubstantiated based on interviews and observations. A deficiency was cited for failure to maintain the facility free of bed bugs, which was cleared during the visit.

The complaint investigation was substantiated for the allegation of bed bugs found in rooms #200, 201, 203, 328, 329, and others. Interviews with residents and staff revealed mixed observations, with some confirming bed bugs and treatment provided. Pest control service reports confirmed bed bug activity. Other allegations about cleanliness, odors, and dietary needs were unsubstantiated.

An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing and regulatory requirements.

The facility was found to be in compliance with all applicable regulations, including fire safety, staffing, medication management, and environmental conditions. No deficiencies were observed during the visit.

The visit was an unannounced complaint investigation triggered by allegations received on 2022-11-17 regarding staff assistance to residents, pest control, and COVID-19 protocol adherence.

The investigation found no preponderance of evidence to substantiate the allegations. Staff were reported to assist residents appropriately, pest control measures were in place and effective, and COVID-19 protocols were generally followed with some resident noncompliance.

The complaint included allegations that staff did not provide proper assistance to a resident, were not mitigating the spread of pests, and were not following COVID-19 protocols. The investigation included interviews with staff, residents, pest control technician, and public health nurse. The allegations were determined to be unsubstantiated.

Unannounced complaint investigation conducted due to allegations that the facility was not kept free of insects and had bed bugs.

The investigation substantiated the allegations that bed bugs and roaches were present in multiple resident rooms, confirmed by staff and residents interviews and pest control records. The facility was found to be in violation of maintenance and operation requirements for cleanliness and pest control.

The complaint was substantiated based on interviews with staff and residents and review of pest control records showing bed bugs and roaches in multiple resident rooms. Bed bugs were found on or about 08/31/2020 and 09/01/2020, and roaches were found on 09/17/2020.

The inspection was an unannounced complaint investigation regarding an allegation that the facility is in disrepair with a leaking air conditioner.

The investigation found that five out of five staff denied the allegation and four out of four residents reported no issues with their air conditioning units. Observations confirmed that resident window air conditioning units were operational. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged the facility had not repaired a leaking air conditioner. The allegation was unsubstantiated after investigation.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 12/31/2020 regarding staff failing to return residents' personal belongings, treating residents with dignity and respect, engaging in verbal altercations, and failing to meet residents' needs.

The investigation included interviews with staff and residents, record reviews, and a facility tour. All allegations were found to be unsubstantiated as interviews and evidence did not corroborate the complaints.

The complaint investigation was unsubstantiated. Allegations included staff failing to return resident's personal belongings, treating residents without dignity and respect, engaging in verbal altercations, and failing to meet residents' needs. Interviews with seven residents and eight staff members did not corroborate any allegations.

The visit was an unannounced case management inspection conducted due to an incident reported to the Community Care Licensing Division on 11/21/2022 involving a resident fall.

The investigation found that Resident #1 had an accidental ground level fall resulting in fractures but no signs of neglect or lack of supervision were identified. No deficiencies were issued.

The complaint involved a fall incident of Resident #1 on 11/20/2022, with injuries including a fractured left knee and right wrist. The complaint was investigated and found to be unsubstantiated with no neglect or lack of supervision.

An unannounced complaint investigation was conducted regarding an allegation that staff were not meeting residents' showering needs.

The investigation found that staff assisted the resident with all showering needs on 11/13/2022 and that the resident prefers showering once a week on Sundays. A meeting was scheduled to discuss the matter further. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff were not meeting residents' showering needs. The investigation included interviews with the resident, staff, and administrator, and review of relevant schedules and agreements. The allegation was found unsubstantiated.

An unannounced complaint investigation was conducted regarding an allegation of illegal eviction of a resident at Kingsley Manor.

The investigation found that the eviction notices issued to the resident were lawful and in compliance with regulations. Despite the resident's claim, there was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.

The complaint alleged illegal eviction of resident #1. Interviews with residents and staff, as well as document reviews, showed that eviction procedures followed required regulations and that the resident had not complied with payment requests since November 2021. The allegation was unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation was conducted to determine the validity of the allegation that staff do not assist a resident (R1) with showering.

The investigation found that staff had not assisted R1 in transferring from the wheelchair to the shower since 09/04/2022 due to a staff injury. The facility's Licensed Vocational Nurse recommended R1 move to a higher level of care. Seven out of eight residents interviewed did not corroborate the allegation. The physician report indicated R1 is ambulatory and capable of self-care, but R1 had not received shower assistance as required. The allegation was substantiated.

The complaint alleged that staff do not assist resident R1 with showering. The allegation was substantiated based on interviews and records reviewed. Staff had not assisted R1 with showering since 09/04/2022. The facility recommended R1 move to a skilled nursing section for higher level care. Seven of eight residents interviewed did not corroborate the allegation. The physician report indicated R1 is ambulatory and capable of self-care. The preponderance of evidence standard was met.

An unannounced complaint investigation was conducted to determine the validity of an allegation that staff do not assist a resident (R1) with showering.

The investigation found that staff have not assisted R1 in transferring from the wheelchair to the shower since 09/04/2022 due to a staff injury. The facility's Licensed Vocational Nurse recommended R1 move to a higher level of care. Seven out of eight other residents reported receiving shower assistance. The allegation was substantiated based on interviews and record reviews.

The complaint alleged that staff do not assist resident R1 with showering. The allegation was substantiated after investigation, with evidence showing R1 has not received shower assistance since 09/04/2022.

The visit was an unannounced complaint investigation conducted to address allegations that facility staff did not assist a resident with showering needs and did not ensure that the resident was taking medications as prescribed.

The investigation found that Resident #1 was independent in self-care and medication management, refused facility care services, and had left the facility following hospitalization. There was insufficient evidence to substantiate the allegations, and both were found to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included neglect/lack of care regarding assistance with showering and medication administration. Interviews, record reviews, and evidence showed no preponderance to prove the alleged violations occurred.

The visit was an unannounced case management inspection to gather information regarding a reported incident where Resident #1 alleged someone touched their private part, as per SOC 341 faxed on 08/22/22.

Interviews and investigation revealed that Resident #1 did not remember the alleged incident and no other allegations were reported. The Licensing Program Analyst found no deficiencies cited during the visit.

The complaint involved an allegation by Resident #1 that someone entered their room and touched their private part, but the resident could not identify the person or the time of the incident. Subsequent interviews indicated a misunderstanding and no substantiated memory of the event by the resident.

An unannounced Case Management - Incident visit was conducted to obtain information on the death of a resident that occurred on June 26, 2022.

The resident was found deceased after falling from the 5th floor balcony. The facility provided notification to the licensing division and relevant documents were obtained for review.

The visit was triggered by the incident and death of a resident on June 26, 2022. The resident was pronounced dead at the scene after falling from the 5th floor balcony. The facility was instructed to submit the Death Certificate and Coroner's report.

An unannounced visit was made for the purpose of an unrelated complaint investigation regarding failure to report an active COVID-19 case at the facility.

The facility had one active COVID-19 case that was not reported to Community Care Licensing as required by regulation, resulting in a cited deficiency for failure to meet reporting requirements.

The visit was triggered by a complaint investigation control # 28-AS-20220613092610. The deficiency was substantiated as the facility did not report a COVID-19 positive resident (R1) diagnosed on June 9, 2022.

The inspection was an unannounced complaint investigation visit triggered by allegations including a resident threatening another resident, calling another resident names, and a resident obtaining bleach.

The investigation substantiated that Resident 4 (R4) threatened and harassed Resident 6 (R6), including invading personal space and making derogatory comments. R4 also poured bleach on R6's door, posing a health and safety risk. Staff and residents reported fear and intimidation caused by R4's behavior, and the facility relocated R6 for safety.

The complaint investigation was substantiated. Allegations included a resident threatening another resident, calling names, and obtaining bleach. Evidence showed R4 threatened and harassed R6, poured bleach on R6's door, and caused fear among residents and staff.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not prevent a resident from engaging in inappropriate behaviors and failed to provide a safe environment for residents in care.

The investigation found that although a resident (R4) exhibited aggressive and inappropriate behaviors causing concern among residents, staff took actions to redirect and keep residents safe, including calling police when necessary. Interviews with staff, residents, and family members indicated that the facility provides a safe environment and prevents inappropriate behaviors. There was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.

The complaint involved allegations that staff failed to prevent a resident from engaging in inappropriate behaviors and failed to provide a safe environment. The resident was physically violent, damaged property, and caused distress among other residents. Staff and management reported efforts to manage the resident's behavior, including police involvement and attempts to evict the resident. Interviews with staff, residents, and family members supported that staff acted appropriately. The complaint was unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was raped by a staff member.

The investigation included interviews with residents, family members, caregivers, and review of hospital medical records. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.

The complaint alleged that a resident was raped by a staff member. Interviews revealed cognitive impairment of the resident and no corroborating evidence was found. Family members and staff denied neglect or abuse. Hospital records showed no trauma or complaints. The allegation was unsubstantiated due to lack of evidence.

An unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices was conducted to evaluate compliance with infection control regulations.

The facility was inspected and toured with no deficiencies observed. COVID-19 infection control practices, signage, PPE supply, social distancing, and food supplies were all found adequate and in compliance with regulations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 10/15/2020 alleging that the facility had vermin.

The investigation substantiated the allegation of vermin presence, specifically rats and cockroaches in the facility kitchen, which led to the kitchen being shut down for 48 hours. Environmental Health Specialist Larry Regalado observed numerous rat droppings and dead cockroaches, and the kitchen was given a Facility Status grade B with a score of 82. The kitchen was cleared and allowed to resume operation after sanitation and elimination of the infestation.

The complaint was substantiated based on evidence including interviews with Executive Director Ted Maneerod, Environmental Health Specialist Larry Regalado, and review of reports. The facility kitchen was found to have rat droppings and dead cockroaches, leading to a 48-hour closure of kitchen operations.

The visit was an unannounced complaint investigation conducted to investigate an allegation that staff did not protect a resident from financial abuse.

The investigation included interviews with residents, caregivers, and the administrator, as well as a review of relevant logs and policies. All residents denied unauthorized withdrawals or transfers of money, and no evidence was found to substantiate the allegation. The complaint was determined to be unsubstantiated with no deficiencies cited.

The complaint alleged that staff did not protect a resident from financial abuse. The investigation found no preponderance of evidence to prove the alleged violation occurred, resulting in an unsubstantiated finding.