It was alleged that staff lock the refrigerator preventing residents from having access. This investigation consisted of interviews with facility staff. On 10/28/2025 LPA Hughes conducted interviews with 2 out of 3 facility staff who confirmed that the facilities refrigerator is locked at night per the request of the licensee. This was observed not in compliance with Title 22 regulation 87468.1(a)(3) as residents in care were not allowed to access the refrigerator as it is locked.

Allegation: Facility staff does not have gloves and facility does not follow infection control plan

It was alleged that the facility staff does not have gloves, and the facility does not follow infection control plan. This investigation consisted of facility observations, and interviews with facility staff. On 10/28/2025 LPA Hughes conducted a visit to the facility, during the visit LPA Hughes observed the facility did not have an adequate supply of gloves for all facility staff, LPA observed 1 box of gloves made available for all facility staff. Additionally, according to the facilities Plan of Operation, the facility did not ensure proper reporting of the scabies outbreak to CCLD, residents and their responsible parties, facility staff, and the Sacramento County Dept of Health, The licensee failed to comply with reporting requirements instructed by the Sacramento County Dept of Health on 11/17/2025 as the outbreak was not reported until 11/24/2025. Facility staff were not provided with appropriate and adequate PPE while caring for residents with body lice. Interview with 2 out of 3 facility staff indicated that they were not made aware of the scabies outbreak for 2 weeks following the diagnosis of residents (R3) and (R4). During this time facility staff did not have an adequate supply of PPE. This was observed not in compliance with Title 22 regulation 87208(a)(1). As the facility did not follow the approved Plan of Operation.

It was alleged that Staff are administering another residents medication to another resident. This investigation consisted of facility observations, and interview with 2 out of 3 facility staff. LPA Hughes conducted a visit to the facility, during facility observation LPA reviewed the medications for residents (R3) and (R4) LPA observed the medications boxed separately, both residents were prescribed the same medication for their current condition with scabies. Interview with facility staff (S1) reflected that residents medications are separate, and residents are not administered other residents’ medications in the facility. Additional interview with 4 out of 4 residents in care, did not express any concerns with medication administration, stating that they are administered their own medications. There is no evidence to corroborate this allegation, therefore this allegation is unsubstantiated.

Allegation: Staff does not keep facility free from pest

It was alleged that Staff do not keep facility free from pests. This investigation consisted of facility observations, and interviews with facility staff. On 10/28/2025 LPA Hughes conducted a visit to the facility, during facility observation LPA did not notice any signs of pest in the facility. LPA reviewed Pest control records for the facility, with the last service date being in August 2025. Interview with 3 out of 3 facility staff indicated that the facility has an active issue with pest in the facility. However, the facility has been proactive in their approach to addressing and mitigating the problem. There is no evidence to corroborate this allegation, therefore this allegation is unsubstantiated.

Allegation: Staff does not properly store medications

It was alleged that Staff does not properly store medications. This investigation consisted of facility observations, and interviews with facility staff. LPA Hughes conducted a tour of the facility and noticed resident’s medications locked and inaccessible to residents in care. Interview with 2 out of 3 facility staff indicated that resident’s medications are locked in a medication cart and inaccessible to residents. There is no evidence to corroborate this allegation, therefore this allegation is unsubstantiated.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.