Royal Oaks

Allegation investigated: Resident was touched inappropriately by another resident due to staff neglect.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation to investigate the allegation listed above. LPA met with Wellness Director Sev Tienda and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Staff and Resident Rosters, Police Report Number for local police departments investigation on same allegation, and conducted interviews with 2 staff and 10 Residents. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Resident was touched inappropriately by another resident due to staff neglect It is alleged that R1 was touched on their breast by R2 and staff did not prevent this from happening. LPA attempted interview with R1, however, R1 refused to be interviewed after multiple attempts. LPA interviewed R2 and it was explained that there was no inappropriate touching, R2 stated they did visit R2 frequently due to R2’s health decline and they just would visit to keep R1 company every so often since they were in bed and not able to participate in activities. R1 stated that they gave a hug to R2 and gave R2 a kiss on the cheek goodbye at the end of a visit, which was normal interaction for both residents, but nothing was ever forced or done in an inappropriate manner. LPA interviewed 10 residents and each denied the allegation and stated they have never been touched inappropriately by any resident or staff and feel safe at the facility. LPA interviewed 2 staff and both denied the allegation and stated that this was brought to their attention by R1 psychiatrist and the facility cross reported to ombudsman, police and licensing after this information was obtained. Facility conducted an investigation as well as the local police department and both residents denied any inappropriate touching, R1 told stated that they were not touched, however, there was a consensual kiss shared with R2. S1 and S2 stated since this incident the care plan for R1 has been updated and both residents have been informed that it would be best for there to no longer be any in room visits to avoid these incidents from reoccurring, and families were contacted, made aware and agree to this plan as well. Based on statements and interviews conducted with staff/residents, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 28-AS-20260723175816

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted the required unannounced annual inspection. LPA met with Director of Wellness, Eusebio Tienda and explained the purpose for the visit. The facility is licensed to serve a capacity of two hundred (250) residents ages 60 and above, with a maximum of (25) Non-Ambulatory in the Bradbury Building. There is an approved Hospice Waiver on file for four (4) residents. The facility also has an approved Dementia Care plan as part of their operation. There are currently 24 residents in Assisted Living and 184 residents in Independent Living. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan in place which was last updated on 08/05/2025. Emergency and disaster plan was completed and up to date. Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance in place. There is an approved Dementia Care plan in place. Last fire drill was last conducted on 09/22/2025. Physical Plant & Environment Safety: This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building and other residents are at the Independent Living care section. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia or wandering behaviors, this was tested during visit and was in order. Physical Plant & Environment Safety [Cont.]: LPA inspected six (6) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. The hot water temperature was tested throughout the facilities resident’s six (6) private bathrooms and measured between 114.9 degrees F to 116.6 degrees F which are within the required range of 105-120 degrees. Cleaning supplies are secure, locked and inaccessible to residents. Sharps are secure, locked and inaccessible to residents. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged and last inspected on 04/14/2025. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. There are multiple shaded patio/garden areas for residents. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: LPA reviewed five (5) staff files that included personnel record, criminal record clearance, health screening, TB clearance, Employee Rights, valid First-Aid/CPR/AED training, and staff training. Executive Director/Administrator, Andrew Smith certificate expires on 2/11/2027. Residents Rights-Information: Residents are provided with telephone and internet access at the facility. The facility has the following posters posted throughout common areas: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables, along with the emergency food supply. Incidental Medical & Dental: Medications were reviewed for five (5) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are centrally stored and in their original containers. Medications are administered as prescribed by the Physician. Medications are bubbled packed and in bottles. The first Aid kit was observed and has all required items. Resident Records-Incident Reports: LPA reviewed five (5) resident files which included Face Sheet, Pre-admission Appraisal/Assessment, Service Plan, Admission Agreements, Physician's Report, Ambulatory Status, TB Clearance, and Personal Rights. There were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites. LPA observed the Evacuation chairs mounted near the stairway. The last drill was conducted on 9/22/25 in the assisted living (Bradbury Building). Residents with Special Health Needs: Per Director of Wellness, there are one (1) residents under hospice care, (0) residents receiving home health services and two (2) residents using oxygen have "No smoking in use" signs posted. Dr.’s Order for one (1) resident’s Hospital Bed is in file. Facility has hospice care plan in place. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to Director of Wellness, Eusebio Tienda.the state’s words, verbatim · CDSS document, Oct 14, 2025

Allegation investigated: Facility staff did not keep resident information confidential. Unqualified staff are providing care to resident(s) in care.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 09/20/2025, to deliver findings regarding the above allegations. On 09/18/2025, LPA Ramirez conducted an unannounced initial complaint investigation. Due to time constraints, additional interviews were needed and additional time to review records, a need further investigation was documented. During today’s visit, LPA Ramirez was greeted by Charge Nurse Anjelica Ponce and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster, Resident Roster, copies of the following for Resident#1 (R1): physician's report, needs and services care plan, and physical plant tour. LPA Ramirez conducted the following interviews: Staff#1 - 7 interviews (S1 – S7) and Resident#1-3 Interviews (R1- R3). SEE 9099-C for continued report Unsubstantiated The investigation revealed the following: regarding the allegation “Facility staff did not keep resident information confidential.” It is alleged staff revealed R1’s confidential medical information to maintenance staff. Seven (7) out of the seven (7) staff interviewed denied this allegation. Interview with S6 revealed a resident’s medical diagnosis or medical condition is not disclosed to them. An interview with S7 revealed maintenance staff do not need to know a resident's medical condition because maintenance only provides repair and maintenance to the buildings and grounds. Three (3) out of the three (3) residents interviewed denied this allegation. Interview with R1 revealed they receive “good care” from staff and felt “safe” at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Unqualified staff are providing care to resident(s) in care.” It is alleged that maintenance staff are providing direct care and supervision to residents. Seven (7) out of the seven (7) staff interviewed denied this allegation. Interview with S3 revealed maintenance would never assist or provide direct care and supervision to residents due to maintenance staff not being qualified or trained to assist residents. Interview with S7 revealed if they observe a resident requests assistance with anything other than maintenance/repairs, they will call for a nurse or caregiver to assist the resident. Three (3) out of the three (3) residents interviewed denied this allegation. All three (3) residents interviewed revealed that maintenance staff have assisted with repairs to their room but denied that maintenance staff have ever assisted them with activities of daily living. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during this complaint investigation. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 20, 2025 · control 28-AS-20250916162947

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Director of Wellness Sev Tienda and explained the purpose for todays visit. The facility is licensed to serve a capacity of two hundred (250) residents ages 60 and above, with a maximum of (25) Non-Ambulatory in the Bradbury Building. There is an approved Hospice Waiver on file for six (4) residents. There is an approved Dementia Care plan is in place. This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building and other residents are at the Independent Living care section. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia or wandering behaviors, this was tested during visit and was in working order. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has sufficient PPE supplies and there is an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, multiple residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facilities residents private bathrooms and measured within the required range of 105-120 degrees. There are multiple shaded patio/garden areas for residents. (continued on 809-C) Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff have criminal record clearance, current First-Aid/CPR/AED, trainings are documented in personnel files. LPA reviewed 10 staff files with no issues observed. Executive Director/Administrator Andrew Smith certificate expires on 2/11/2025. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 10 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted throughout common areas: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchens were observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables, along with the emergency food supply. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. LPA toured Medication Room within the Bradbury Building with no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 9/11/24 in the assisted living (Bradbury Building) and on 9/25/24 in the Independent Living. Residents with Special Health Needs: There are currently no residents in the facility on Hospice, however, staff are properly trained to assist with resident who have special health needs. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit. Exit interview held and a copy of the report was provided to Director of Wellness Sev Tiendathe state’s words, verbatim · CDSS document, Oct 14, 2024

Allegation investigated: Staff do not provide adequate food service to residents. Staff do not ensure resident is bathed.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced 10-day complaint visit regarding the above allegations. LPA met with Tony Agoncillo, Health Services Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA toured the facility's building that provides accommodation for the Assisted Living and Skilled Nursing residents. LPA obtained copies of the Staff & Resident Rosters (AL), R1 & R2’s files such as: Functional Capability Assessment, Appraisal/Needs and Services Plan, Physician’s Report, Admission Agreement, Care Plan and copy of residents shower schedule. LPA also obtained the Weekly menu, Meal schedule, Caregivers assignment sheets, Caregivers schedule and Charting notes. LPA conducted interviews with Staff #1 (S1) - Staff #4 (S4) and Resident #3 (R3) - Resident #10 (R10). LPA attempted to interview Resident #1 (R1)-Resident #2 (R2), but unsuccessful as R1 was in SNF being treated, and R2 was asleep. Staff #4 (S4) was off for the day, and LPA's attempt to do phone interview was unsuccessful due to S4 did not answer and voicemail full. Additionally, Staff #6 (S6) was away, therefore not interviewed. ******CONTINUED ON LIC9099-C***** Unsubstantiated Investigation revealed the following: In regards to allegation: “Staff do not provide adequate food service to residents.” It is alleged that staff sleep during shift and would not wake up to feed the residents breakfast or lunch nor help and feed the residents who need assistance with feeding. Interviews conducted with (5) out of (5) staff denied the allegation. Staff stated that they provide 3 meals a day and the residents are being fed on time. Staff stated that they never heard or witnessed any caregivers failed to provide meals to the residents. S1-S2 stated that they have zero tolerance about staff sleeping on the job and will be automatically written up. S2 indicated that caregivers in the Home Care Dept. provide companionship and additional support to residents who requested the service. Interviewed residents denied the allegation and stated that they eat their meals on time. Some residents stated that their caregivers assist them with feeding. During the visit, LPA observed residents eating lunch in the dining area and in the hallway, there was a cart filled with food trays being delivered to the residents rooms. LPA reviewed R1's charting notes and observed that S5 assisted R1 with feeding during her shift. Therefore there was insufficient evidence to corroborate with the allegation. In regards to allegation: “Staff do not ensure resident is bathed.” It is alleged that the resident was supposed to get a shower, but staff didn’t do it. Staff interviewed denied the allegation and stated that they never heard this type of complaint. Staff indicated that residents who require shower assistance are accommodated according to their scheduled shower days. Staff stated that residents are given showers either daily or every other day depending on what the resident wants. S2 stated that CNAs are responsible with showering the residents, but caregivers may assist depending on the resident's condition. Interviewed residents denied the allegation. Some residents stated that they take a shower on schedule and get assistance with showering if they ask. LPA reviewed the shower schedule which showed the list of residents who are in need of shower assistance and on which days of the week the services are provided. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held and a copy of this report was provided to Tony Agoncillo, Health Services Administrator.the state’s words, verbatim · CDSS document, Apr 4, 2024 · control 28-AS-20240326115044

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Health Services Administrator, Tony Agoncillo and Nurse director, Eusebio (Sev) Tienda, who assisted with the visit. LPA discussed the purpose of today's visit with administrator. During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, toured the facility, reviewed food supply, reviewed medications, and reviewed staff/residents records. The facility is licensed to serve two hundred fifty (250) residents ages 60 and above. A maximum of 25 Non-Ambulatory residents in the Bradbury Oaks building. Facility has approved Hospice Waiver for four (4) residents. Currently, there is one (1) resident on hospice. Approved Dementia Care plan is in place. This is a Continuing Care Retirement Community (CCRC) which includes three separate levels of care; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building which had 28 residents. Other residents are living at the Independent Living care section. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia, who have wandering behaviors. Medications were centrally stored, locked and inaccessible to residents in care. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. (-continued in LIC 809 C-) Hot water temperature is in a range of 107.5 to 118.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility. All exit doors are equipped with "wander guard system." Signal system is operational. Last emergency drill is conducted on 9/20/23 and fire drill on 7/18/23. Sufficient supply of perishable and non-perishable foods is observed. Kitchen has required equipment and is in compliance. Smoke detectors and carbon monoxide detectors are monitored by a fire prevention company. All mandated documents and signages are posted in common areas. No deficiency was cited per California Code of Regulations, Title 22. An exit interview was conducted and this report was discussed with Nurse Director, Eusebio P (Sev) Tienda.the state’s words, verbatim · CDSS document, Oct 24, 2023

Allegation investigated: Staff did not respond to resident's call for assistance in a timely manner. Staff did not provide medical assistance to resident in a timely manner. Food services are inadequate. Staff do not ensure resident's special diet is followed. Staff did not safeguard resident's personal belongings. Staff threatened resident. Staff placed unsafe equipment in resident's room. Facility is in disrepair. Facility did not follow Covid-19 testing protocols.

** This report supersedes report dated 8/24/23. LPA Villalobos gathered additional information and conducted further interviews regarding the allegations above. There are no changes to the findings** Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced subsequent complaint visit to the facility. Upon arrival, LPA met with Jill Crowell (Director of Resident Services) and explained the purpose of the visit. A short time later Eusebio (Sev) Tiendia (Director of Wellness) also met with LPA and assisted with the complaint investigation. During the initial visit on 09/21/22, LPA Kruz obtained a copy of the Staff/Resident rosters, Admission Agreement (R#1) and Charge Statement. LPA also toured the facility with Jill Crowell, interviewed Staff #1 and #2 (S1-S2) in the conference room and interviewed Resident #1 (R#1) in their living unit. During the second visit on 8/24/23, LPA Kruz obtained a copy of the Staff/Resident rosters and interviewed Residents #2 to #10 (R2-R10) in the office. (Continued on LIC 9099-C) Unsubstantiated On todays visit, LPA Villalobos toured the physical plant, interviewed staff #1-#7 (S1-S7), Collected work order report for R1's room, incident report for R1 dated 4/28/22, and R1's facesheet with physicians report. The investigation revealed the following: In regards to the allegation "Staff did not respond to resident's call for assistance in a timely manner." it was alleged R1 pulled the emergency cord in their room and no assistance arrived until 17 hours later. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. Interview with staff stated that R1 did have an unwitnessed fall in their room on 4/28/22. R1 is an independent living resident of the facility. Interviews state there are no signal or pull cords on 4/28/22 for R1's room. Interviews with staff state that there is a sensor that signals staff when a resident in the independent living rooms does not get out of bed by 10am. When they are alerted, staff will call the room to check on the resident and if there is no answer, they conduct a check. On 4/28/23 this specific signal came for R1's room and staff went to check on R1 and that is when they were observed on the floor by their bedside. There was no pull cord used by R1 and as R1 is an independent living resident, there are no continuous monitoring of residents location throughout the day other then the previous mentioned 10am signal. Interviews with other residents show that staff respond timely to emergency pull cords and there are no issues regarding staff timely responses. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff did not provide medical assistance to resident in a timely manner" it was alleged that R1 fell in their room and was not provided medical assistance in a timely manner. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. File review shows that R1 had a fall on 4/28/22 and was assisted by staff. R1 was transported to the hospital and returned to the facilities skilled nursing department. Interviews show that R1 was assisted immediately after being found on the floor by their bedside on 4/28/22. Resident interviews indicate medical assistance is provided by staff when needed. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. (Continued on LIC 9099-C) In regards to the allegation "Food services are inadequate." it was alleged that the food is dry and given in small portions. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. LPA toured the kitchen and observed all food are of good quality. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days is maintained. Interviews with Staff indicate food service is adequate. Interviews with (9) of (10) Residents indicate food service is adequate and different food choices are available. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff do not ensure resident's special diet is followed." it was alleged that staff do not follow the list of foods R1 can eat. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Per allegation details, it was alleged the facility is not providing Resident #1 with a special diet. Investigation revealed Resident #1 does not require a special diet and there is no physician's order for a special diet. Interviews with staff indicate residents requiring a special diet is provided with meals based on physician's order. LPA Villalobos reviewed R1's file and did not observe a physicians order for special diet. LPA observed a hand written letter by R1 of R1's preferred meals and methods of cooking their meals. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff did not safeguard resident's personal belongings" it was alleged that staff damaged R1's personal item and did not correct the situation and that medications were missing from their room. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interviews show there was a day when staff damaged one of R1's personal items accidentally while conducting repairs to the living unit. Facility immediately reimbursed Resident #1 for the damaged item. LPA observed and collected documentation showing that R1 was compensated. Interviews show R1 accepted the compensation. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. (Continued on LIC 9099-C) In regards to the allegation "Staff threatened resident" it was alleged that S1 threatened R1 to sign documentation of money they were reimbursed. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. Staff interviewed denied that S1 ever threatened R1. Interviews with residents does not show staff to speaking to them in a threatening manner or to any other residents. LPA was not provided with proof that S1 threatened R1. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff placed unsafe equipment in resident's room." it was alleged that facility staff placed a dangerous gas powered heater in R1's room. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed denied the allegation. Interviews with staff state that there are no gas powered heaters in any rooms or any that are provided to residents. There are small electric powered heaters that can be provided upon request if a resident chooses. No gas heaters were observed throughout the visits. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Facility is in disrepair." it was alleged that there are multiple leaks and issues with the bathroom in R1's room that staff were not addressing. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegations. Interviews with staff and residents shows that items that need repair are completed in a timely manner. Work orders are completed and assigned dates to staff to complete. LPA observed work orders for leaks and ceiling repairs completed in R1's bathroom between 4/21/22-4/28/22. Residents interviewed stated the facility is always clean and in good repair and if an item is broken, an order is placed and maintenance will repair it right away. LPA's observed the facility to be clean and in good repair during visits. R1 stated that staff do repair the issues when they are informed of them. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. (Continued on LIC 9099-C) In regards to the allegation "Facility did not follow Covid-19 testing protocols" it was alleged that the facility is supposed to test everyone for covid and never did. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. During the initial visit, Staff checked LPA Kruz's temperature and was provided a Covid-19 questionnaire. Interviews with Staff indicate Covid-19 testing protocols were followed. Interviews with residents also indicated Covid-19 testing protocols were followed. During LPA Villalobos' visit, there are no requirements regarding covid screening. Interviews with staff shows that the only people who are testing for covid 19 at the moment would be someone who has tested positive on their own or anyone who is suspected of having covid due to exposure. Other than that, there is no policy to test residents and staff regularly. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 28-AS-20220915141701