Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

An exit interview was conducted with the Administrator, Diana Castellanos. A copy of the report and appeal rights were provided.

Allegation: “Staff spoke inappropriately towards the residents.” It is alleged that the staff were not talking to the residents with dignity, respect and love. It is also alleged that the residents are afraid to report due to fear of retaliation. LPA interviewed the Administrator and three (3) out of three (3) staff that denied the allegation stating that all staff speak with residents with respect, dignity, and love and have not witnessed any other staff speak to residents without respect, dignity, and love. LPA interviewed one (1) out of four (4) residents and one (1) former resident that stated that there are some staff that speak to them in a frustrated and unfriendly tone but stated that there are some staff that treat them in a pleasant manner. LPA interviewed three (3) out of four (4) residents that denied the allegation stating that they are treated by staff with dignity, respect, and love and have not been mistreated by staff. There is not enough evidence to substantiate.

Allegation: “Staff did not provide adequate care and supervision.” It is alleged that facility staff are not conducting checks on bed bound residents. The residents are left to help themselves and the current residents need skilled care to provide resources. The Administrator, three (3) out of three (3) staff interviewed denied the allegation. LPA interviewed three (3) out of four (4) residents interviewed denied the allegation stating that their cares are met. LPA reviewed the Repositioning/Diaper Change log in January 2026 that their bed bound resident was repositioned/changed every two hours. Based on staff and record review and interview, there are two (2) caregivers on duty per shift. All residents indicated that there are sufficient staff available to help provide care and supervision to meet their needs. LPA observed at the facility that the residents were being closely supervised by the care staff and that there were no immediate health or safety concerns. LPA interviewed two (2) residents that are bedbound stating that they are checked daily by staff.

Allegation: “Staff did not provide adequate food service” and “Staff do not ensure a resident is being properly fed.” It is alleged that residents lost a lot of weight due to the food portions were not sufficient and the diets did not contain protein items. It is also alleged that the facility had to do Uber Eats to get enough food due to the staff not providing snacks in between meals. It is alleged that the residents are not allowed to put their food in the refrigerator due to the kitchen being "closed" for the night. LPA interviewed the Administrator and three (3) out of three (3) staff and they all denied the allegation. All staff interviewed indicated that all residents at the facility receive three meals and three snacks per day. All staff interviewed also indicated that facility provides a sufficient amount of food to all of the residents in care. LPA interviewed three (3) out of four (4) residents all claim they get enough food from the facility staff. LPA interviewed one (1) out of four (4) residents and one (1) former resident that corroborated with the allegation stating that they are not satisfied with the food served and that residents have lost weight due to lack of variety, alternate choices, and protein. LPA observed four (4) residents eating their meal at the dining hall during lunch time from 12:05pm to 12:30pm. LPA observed eating the following items: Empanadas, potato pie, avocadoes, Jello, and beverage. Residents were in a pleasant mood while continuing to eat lunch. LPA observed no concerns regarding residents not getting enough food from the facility. LPA reviewed S1 to S3’s file that included staff training on Cultural Competency and Sensitivity conducted on September 2025. There is not enough sufficient evidence to substantiate.

Allegation: “Staff did not provide adequate lighting for the residents.” It is alleged that the home has no lights in the hallway and the staff would not assist when residents needed to get up at night to use the bathroom. LPA interviewed Administrator and three (3) out of three (3) staff that denied the allegation stating that adequate lighting is provided and they assist residents at night to use the restroom. LPA interviewed one (1) out of four (4) residents and one (1) former resident corroborated with the allegation stating that the hallway lights are not turned on at night by staff when residents need to go to the restroom. LPA interviewed three (3) out of four (4) residents that denied the allegation stating that there is adequate lighting all day and night so that staff can help provide assistance for residents to go to the restroom. LPA observed that hallway lights are on and per Administrator that they are on at night to assist residents to go to the restroom. There is not enough sufficient evidence to substantiate.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, 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 allegations are UNSUBSTANTIATED.