Silverado Senior Living-San Juan Capistrano

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Licensee did not make available confidential information upon written consent from resident's designated representative

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry and explained the reason for the visit. During the course of the investigation, LPA interviewed Administrator. Regarding the allegation that licensee did not make available confidential information upon written consent from resident's designated representative, the investigation revealed the following: Resident 1's (R1) designee requested a copy of the resident's record on July 30, 2026. Administrator confirms receiving request in the late evening on July 30, 2026. Administrator notified the home office same day. Administrator began to gather the records for submittal to home office on August 3, 2026. As of August 10, 2026, R1's designee had not received the requested records violating §1569.269(a)(21) which states resident records must be provided upon request within two business days. CONTINUED ON LIC 9099C DATED 08/13/2026 Substantiated Based on interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegation is deemed Substantiated. Deficiency being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 22-AS-20260805161645

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Aug 20, 2026

Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days..This req is not met as evidenced by: Based on interviews conducted, Licensee failed to ensure R1's records were provided within two business days which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee agrees to forward proof that records have been provided to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to the department. LPA was greeted and granted entry and explained the reason for the visit. SOC 341 submitted to the department on 06/13/2026 indicated Resident 1 (R1) had verbalized that Staff 1 (S1) had been rough with the resident. Law enforcement was called and OC Sheriff responded, case #061226-0719. The staff was immediately suspended pending an investigation and subsequently terminated. LPA observed S1 signed the "Acknowledgment to Report Elder Abuse" on 08/20/2024. LPA observed S1's current training records. Interview with R1 confirmed the incident notated on the SOC 341. Incident report dated 07/06/2026 indicated S2 had administered metronidazole 250mg, orally to R2 instead of placing on the resident's heel as directed. S2 notified management and poison control was contacted. Resident was monitored per poison control recommendations and no adverse affects were noted. Per Silverado assessment dated 03/23/2026, R2 is diagnosed with Dementia and unable to administer own medications. Resident appraisal dated 03/21/2026 indicates R2 has wounds on the heels of both feet. R2 is on hospice care. Based on the observations made during today's visit, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Jul 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 23, 2026

Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications..This req is not met as evidenced by: Based on record review, Licensee failed to ensure R2 was assisted with proper administration of medications. R2 was administered metronidazole 250mg orally when the order indicates it is to be administered topically which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Licensee agrees to conduct an in-service on medication administration and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a) · Plan of correction due date: Jul 23, 2026

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This req is not met as evidenced by: Based on interviews conducted and record review, Licensee failed to ensure R1 was accorded dignity at the facility. S1 was reportedly rough with the resident and was subsequently terminated which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Licensee agrees to conduct an in-service on personal rights and forward proof to LPA by POC due date.

Allegation investigated: Staff did not adequatey address a change in resident's health condition.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA spoke with Stephanie Grogan, Office Services Manager and explained the purpose of the visit. Casey Lambert, Intreim Administrator arrived shorty after and met with LPA. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, interviews conducted, and copies of pertinent records. It is alleged staff did not adequately address a change in resident’s health condition. Records review reflects all medication for resident (R1) has a prescription and was prescribed by a skilled propressional. Review of R1's MAR sheets reflect medication was administered as prescribed. Mediation for R1 were followed as prescribed and adjusted as prescribed by a skilled professional. R1 had an adjustment of medication on Continued on LIC9099-C Unsubstantiated October and November, 2025, when R1 had incidents. R1 had a re-assessment of their care plan in October and November of 2025. Care plan was updated in October after R1 was noted with a change in condition in the community where 911 was called to assess the situation. R1 was sent to the hospital for further evaluation and was discharged back to the community with medication change and behavior mapping. Care plan was updated in November after R1 had a behavior episode that required 911 to be called and sent out for further evaluation. R1 returned to the facility and was placed on a 1:1 care. Interviews with 4 of 4 staff stated that it was first observed that R1 had a change of condition in October and November and a new care plan was assessed based on these changes. Staff stated that medication was handled as prescribed and had changes to medication from the incident in October and when R1 was admitted to hospice. Prior to those incidents R1 did not have an observed change of condition that needed to be addressed and/or needed medication changed due to a change of condition. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation are deemed Unsubstantiated. An exit interview was conducted with the facility representatives and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, May 12, 2026 · control 22-AS-20251130221835

Type of visit: Required - 1 Year

On March 18, 2026, Licensing Program Analysts (LPAs) Joseph Alejandre and Garlli Tat made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with Casey Lambert, Director of Resident and Family Services, and explained the reason for the visit. The Executive Director, Sheila Fike, Administrator's Certificate expires on July 17, 2027. The facility is licensed for 96 non-ambulatory residents. Facility is a single story building with a central courtyard. LPAs and the Director of Resident and Family Services toured the facility. LPAs observed the See Something, Say Something poster (PUB 475) posted in the main entrance of the facility. LPAs observed all the required postings in the lobby area of the facility. LPAs observed the central courtyard has a covered patio with tables and chairs to sit outside. There is a circular path for walking and a gazebo. There is one small raised fountain in the courtyard. No obstacles or hazards observed in the courtyard. The facility is approved for delayed egress. LPAs tested the delayed egress doors. The delayed egress doors are operational. LPAs observed fire extinguishers throughout the facility. All fire extinguishers are fully charged. The last emergency drill was conducted on January 21, 2026. LPAs toured 8 resident rooms. LPAs observed all the resident rooms had the required bed linens and furnishings. Hot water measured 119.6 to 125.9 degrees Fahrenheit. LPAs observed medication is kept locked in the medication cart stored in the medication room. LPAs inspected the first aid kit. The first aid kit had all the required elements. LPAs observed both (2) medication carts were locked. Continued on LIC-809C. LPAs observed all cleaning supplies are kept locked in a storage room. LPAs observed the kitchen is clean and organized. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. All refrigerators and freezers were at the required temperatures. LPAs observed a 3 day supply of emergency food and water in the storage room. LPAs observed lunch being prepared in the kitchen and lunch being served in the dining room. LPAs observed residents participating in arts and crafts. No obstacles or hazards were observed in the facility. LPAs observed an activity room with games and a TV. LPAs reviewed 8 resident files and medications. LPAs observed Resident #1 (R1) and Resident #2 (R2) were missing PRN medications. R1 was missing Alprazolam .25mg and R2 was missing Amlodipine Besylate 5mg. LPAs reviewed 10 staff files (caregivers). All 10 staff members had 20 hours of annual training, including 8 hours of Dementia training, but did not have 4 hours of training for Restricted Health Conditions, Postural Supports, and Hospice care. All staff whose files were reviewed are background cleared and associated to the facility. Deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Mar 18, 2026

Allegation investigated: Staff did ensure resident's needs were being met. Staff did not seek medical attention to resident. Staff did not safeguard resident's personal belongings. Staff did not issue responsible party a refund.

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to deliver findings regarding the allegations. LPA met with Executive Director Sheila Fike and explained the purpose of the visit.During the course of the investigation, LPA conducted interviews with three staff members, three residents, and reviewed relevant facility records.The first allegation stated that staff did not ensure residents’ needs were being met. LPA conducted interviews with three staff members and three residents, all of whom denied the allegation.The second allegation stated that staff did not seek medical attention for a resident. LPA interviewed three staff members and three residents, all of whom denied the allegation. In addition, LPA searched the Community Care Licensing database for any Special Incident Reports (SIRs) submitted by the facility and found no record of reporting related to the allegation. Unsubstantiated The third allegation stated that staff did not safeguard a resident’s personal belongings. LPA conducted interviews with three staff members and three residents, all of whom denied the allegation. LPA also reviewed the Resident Inventory and confirmed that the alleged missing item was located in the laundry and subsequently returned to the resident. LPA contacted the reporting party, who confirmed the item had been received.The fourth allegation stated that facility failed to issue a refund to a responsible party. LPA reviewed facility records and email correspondence with the facility’s home office, which confirmed that a refund check (check number 5638) was issued on March 19, 2025, and cleared on March 25, 2025.Based on evidence obtained through interviews, record reviews, and observations, there is not a preponderance of evidence to support that the alleged violations occurred. Therefore, the allegations are deemed unsubstantiated. This means that while the reported concerns may have occurred or may be valid, there is insufficient evidence to prove the facility violated applicable regulations.No deficiencies were cited during today’s visit. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 22-AS-20250307105005

Allegation investigated: Staff did not ensure resident's shower needs were met

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Shila Fike and explained the reason for today’s inspection. The investigation into the allegation that staff did not ensure resident's shower needs were met revealed the following: During the course of the investigation, Licensing Program Analysts (LPAs) Sean Haddad and Jenifer Tirre inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s shower log. CONTINUED Substantiated It was alleged that Resident #1 (R1) was not showered for multiple days. Seven staff interviewed denied the allegation, stating that R1 received showers at least twice a week, R1 rarely refused showers, and that if R1 did refuse a shower facility staff would attempt multiple times to complete the shower for R1. Seven out of seven residents interviewed did not raise concerns about not receiving enough showers. However, review of the facility’s shower log revealed that R1 did not receive a shower on October 5, 6, 7, 8, 9, 10, or 11, 2024, and while a single refusal was documented on October 8, 2024, there is no documentation of additional attempts to offer R1 a shower until another single refusal was documented on October 11, 2024. AD reviewed the shower log and confirmed that it shows that R1 did not receive a shower during this period. While R1 had the right to refuse showers, facility staff did not make and document multiple attempts to assist R1 with showers. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that staff did not safeguard resident's personal items: it was alleged that R1’s shaver disappeared and that they were observed wearing their roommate’s underwear. Seven out of seven staff interviewed denied the allegation, stating that personal items and clothing are logged, the facility will look for and replace any missing items, residents sometimes do inadvertently take clothing that is not theirs, but that staff will wash and return any clothes taken by other residents if they are made aware of the issue. Review of R1’s inventory lists revealed that R1's clothing and personal items were thoroughly itemized, but the lists did not include a shaver. Seven out of seven residents interviewed raised no concerns about missing items or mixed-up clothing. While incidents of items going missing and residents’ clothing getting mixed up may happen occasionally, the information obtained did not corroborate that the facility is not taking sufficient measures to prevent these issues. Regarding the allegation that staff allow residents to use the same toothbrush: it was alleged that, in R1’s bathroom which R1 shared with their roommate, three toothbrushes were observed in the same cup and only one shaver, indicating that both residents are using the same shaver and potentially the same toothbrush. Seven out of seven staff interviewed denied the allegation, indicating that residents have their own labeled storage area in the bathroom for their hygiene items. Two of these staff stated that residents are assisted by staff while brushing their teeth. LPA Tirre observed that residents had personal labeled storage spaces for their hygiene items in their bathrooms. LPA Haddad inspected the toothbrushes for seven residents and noted that toothbrushes were either locked in the bathroom storage closet, accessible on the bathroom counter and labeled with resident names, or accessible on the counter if the resident had no roommate. Interviews with seven residents revealed that residents are either aware of which toothbrush is theirs and are able to access them or they receive assistance from staff when it is time to brush their teeth. While it is possible that residents are using the toothbrushes of other residents while staff are not present to assist them, the information obtained is conflicting. Regarding the allegation that staff did not prevent resident from engaging in an altercation with another resident in care: it was alleged that R1 engaged in two altercations with another resident and that facility staff did not prevent this from occurring. Per R1’s Physician’s Report dated July 16, 2024, R1 is diagnosed with Dementia, is ambulatory, and has confusion, aggressive behavior, and wandering behavior. Seven out of seven staff interviewed denied the allegation, stating that residents who engage in altercations are separated and that measures are taken to prevent future altercations. Two staff interviewed confirmed that R1 got into two altercations with another resident and that in response to the first altercation the facility placed R1 on one-on-one supervision for 72 hours and requested a medical reassessment including significant medication adjustment for R1. Per R1’s care notes, on October 16, 2024, at 6:30AM, R1 was involved in an altercation where R1 pushed another resident to the ground and facility staff notified R1’s family that due to R1’s behavior, R1 needs one-on-one supervision and a medication change. No information was obtained that R1 did not receive the one-on-one care as required. Per R1’s Medication Administration Record, R1 received all of their medications as prescribed in September and October 2024. Per AD, facility staff and R1’s family agreed that R1’s current doctor was not responding to the situation properly, so it was agreed to have R1 seen by a new doctor, R1’s family fully participated in the care plan meeting with the new doctor, agreed to the medication changes, and agreed for the medications to be sent to a new pharmacy since the new doctor was not allowed to send the medication order to R1’s old pharmacy. The information obtained regarding the second altercation is conflicting. Per witness statement, the second altercation took place on October 20, 2024, but per R1’s care notes and AD, the second altercation was a verbal altercation that took place on October 24, 2024. No information was obtained that there were any physical altercations involving R1 after the October 16, 2024, altercation. It was also alleged that R1 was bullied by the resident they pushed, that this other resident was witnessed bullying other residents and R1 multiple times, and that R1’s family requested the facility to keep them separated but facility staff did not properly redirect them when they got into verbal altercations or the other resident bullied R1. However, the only confirmed physical altercation took place on October 16, 2024, where R1 was the physical aggressor and the information obtained showed the facility properly addressed R1’s aggression. Seven out of seven residents interviewed reported they received good care at the facility and reported no concerns about their safety. While there may have been instances of bullying between residents, the information obtained did not corroborate that the facility did not properly address resident conflicts when they rose to the level of physical altercations. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 22-AS-20241029123104

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 3, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure R1 received assistance with showers by not making multiple attempts to assist R1 with showers in response to R1’s refusals, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: The licensee stated they will retrain staff on resident care refusals and submit proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with the Executive Director Sheila Fike and explained the reason for the visit. The Executive Director's Administrator's Certificate expires on July 17, 2025. The facility is licensed for 96 non-ambulatory residents with a hospice waiver for 20. Facility is a single story building with a central courtyard. LPA and the Executive Director and the Director of Health Services toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entrance of the facility. LPA observed the central courtyard has a covered patio with tables and chairs to sit outside. There is a circular path for walking and a gazebo There is one small raised fountain in the courtyard. No obstacles or hazards observed in the courtyard. The facility is approved for delayed egress. LPA tested the delayed egress doors. The delayed egress doors are operational. LPA observed fire extinguishers throughout the facility. All fire extinguishers are fully charged. The last emergency drill was conducted on November 13, 2024. LPA toured 10 resident rooms. LPA observed all the resident rooms had the required bed linens and furnishings. Hot water measured 111.3 to 120.5 degrees Fahrenheit. LPA observed medication is kept locked in the medication cart stored in the medication room. LPA inspected the first aid kit. The first aid kit did not contain a current edition first aid manual. LPA observed both (2) medication carts were locked. LPA observed all cleaning supplies are kept locked in a storage room. LPA observed the kitchen is clean and organized. LPA observed a 2 perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day supply of emergency food and water in the kitchen. LPA observed lunch being prepared in the kitchen and lunch being served in the dining room. LPA observed residents participating in an arts and crafts. No obstacles or hazards in the facility. LPA observed an activity room with games and a TV. LPA reviewed 10 resident files and medications. No discrepancies observed. LPA reviewed 7 staff files, no discrepancies observed. Staff had the required training. All staff All staff observed at the facility are background cleared and associated to the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Feb 7, 2025

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff member is abusing residents in care.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the investigation into the allegation listed above. LPA met with Executive Director Sheila Fike and explained the reason for the visit. The investigation into the allegation revealed the following. It was alleged that staff at the facility wake up residents at 4 am or 5 am in the morning so the staff arriving at 6 am are not overwhelmed by having to get all the residents up and ready at the same time. The residents would then be put in a common area and stay there until breakfast is served. Breakfast is served from 7:30 am to 9 am. There would be no reason to wake residents unless there was an emergency or medical reason to wake them up. 14 out of 14 witnesses interviewed provided conflicting information regarding the allegation. None of the witnesses interviewed could corroborate the allegation. All individuals interviewed did report that none of the residents are abused or treated poorly. Based on the evidence gathered there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation, staff member is abusing residents in care is deemed UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 12, 2024 · control 22-AS-20220825163549

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director (ED) Sheila Fike and explained the reason for the visit. Sheila Fike's Administrator's certificate expires 7/17/2025. LPA and ED toured the facility. Facility is a single story building with 44 resident rooms. LPA and ED toured 7 resident rooms. LPA observed the see something say something poster (PUB 475) is only 14 X 22 inches. LPA observed all resident rooms had the required furnishings. Each room had it's own carbon monoxide detector, all tested operational. Hot water measured from 116.6 degrees Fahrenheit to 121.0 degrees Fahrenheit. LPA observed the bathrooms were clean and operational. During the visit LPA observed the Director of Plant Operations setting the hot water temperature to 120.0 degrees Fahrenheit. LPA observed all hallways were free of obstruction. LPA and ED toured the kitchen and dining room. LPA observed the kitchen is clean and organized. LPA observed all the refrigerators and freezers had temperature logs. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed an emergency food and water supply on hand in the kitchen. LPA and the ED toured the courtyard of the facility. There is a raised fountain in the courtyard. There are seating areas with tables and chairs in the courtyard with umbrellas for shade. No obstacles or hazards observed outside of the facility. LPA observed all fire extinguishers in the facility are fully charged. LPA observed all medication is kept locked in medication carts which are stored in the medication room. LPA observed the first aid kit in the medication room has all the required elements. LPA reviewed 6 resident files and medications. No discrepancies observed. LPA reviewed 6 staff files. LPA observed 1 out of 6 staff members did not have the required 20 hours of annual training. Based on the observations made during today’s visit deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided. An exit interview was conducted and a copy of the report ( LIC 809) provided along with citations (LIC 809D) and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 12, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow-up on an incident report received by Community Care Licensing on 1/30/2024. LPA met with Executive Director (ED) Sheila Fike and explained the reason for the visit. Incident report indicated that on 1/28/2024, Resident 1’s (R1’s) girlfriend reported to Staff 2 (S2) that R1 informed her that on 1/25/24, Staff 1 (S1) asked R1 “do you want me to put my finger up your butt” to which R1 responded "no." During today’s inspection, LPA interviewed R1 in their respective bedroom. R1 confirmed the incident took place but was unable to provide details leading up to the incident, or where it took place. Per R1, they did not report the incident to staff, nor did they mention it to any residents. LPA interviewed R1’s girlfriend by phone and they confirmed R1 had informed them of the incident, but denied knowing specifics and stated they did not know the name of the staff alleged to have made the remark. During their interview, S2 stated that they had interviewed R1 after R1’s girlfriend reported the incident. Per S2, R1 confirmed the incident took place, but was unable to provide details regarding when and where it took place. ED stated during their interview, that S1 was immediately suspended pending an internal investigation. Per ED, internal investigation consisted of interviews with staff and residents and found the incident to be unsubstantiated. ED stated staff and residents denied witnessing or having any knowledge regarding the incident and reported no concerns regarding S1. Per ED, S1 denied the incident ever took place. ED stated they also do not have any concerns regarding S1. LPA interviewed S1 by phone during today’s inspection. S1 denied the incident ever taking place and stated they would never ask or make a remark such as the one being alleged. (Cont. LIC809-C) LPA reviewed R1’s Physician Report (LIC 602) dated 2/13/23. Per LIC602, R1 is diagnosed with dementia and at times is confused or disoriented. Based on information gathered and due to conflicting information provided during interviews, LPA is unable to determine if alleged violation did or did not occur and no further action is required. Based on observation’s made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 8, 2024