Complaint·May 29, 2026

Continued from LIC9099 Investigation Findings: It was reported to the department that staff waited approximately 60 minutes prior to calling 911. S3 stated S3 noticed at 8:30 AM that the bathroom door where R1 was found was locked. S3 returned at 9:30 AM to open and clean the bathroom when S3 found R1 unresponsive and yelled for someone to call 911. S8 stated S3 informed S8 about 9:50 AM that S3 found R1 unresponsive and to call 911. S6 reported hearing S3 call for someone to call for 911 and did so at 8:30 AM. According to the Oakland Fire Department (FD) Incident Report, the FD wasn’t notified of R1’s need for emergency services until approximately 10:21 AM. When asked by the FD why facility staff waited 60 minutes before calling 911, the Med Tech on duty was unable to explain, therefore the allegation is SUBSTANTIATED. Based interviews conducted during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in an additional civil penalty. Deficiency and plan and proof of correction were discussed with Executive Director Anna Reddy. Exit interview conducted, Appeal Rights, and a copy this report provided. Continued from LIC9099 Investigation Findings: It was reported to the department that Neglect and Lack of Care by staff resulted in the death of resident. According to the Death Certificate, R1’s immediate cause of death was due to cardiopulmonary arrest, onset interval of minutes and coronary artery disease, onset interval of years. According to the coroner’s report, R1’s manner of death was natural, stemming from cardiopulmonary arrest and coronary artery disease. The coroner’s office reported that providing or seeking medical attention sooner would not have made a difference in the cause of R1’s death While it is believed that facility staff failed to perform, and/or properly perform CPR on R1 upon finding R1 unresponsive and non-breathing, there is no indication this resulted in R1’s death. Based on the Death Certificate findings, the allegation is UNSUBSTANTIATED. Allegation: Staff engaged in the misuse of the emergency 9-1-1 system Investigation Findings: It was reported to the department that the facility staff have judiciously used the 911 system for a wide array of calls, including running out of art supplies, residents being thirsty, or the inability of the residents to get in touch with staff for a simple aspirin, thus calling 911 for assistance. Normally, 911 crew are met with a shrug of the shoulder from staff during these calls. These types of calls can be categorized as an annoyance and/or abuse of the 911 system. LPA interviewed O1 on the phone, who stated that EMT will come out to the facility for calls that are determined, upon arrival, to be non-emergency and will vary from things like someone fell and no one wanted to lift the person, to simple things that a person acting as a “Good Samaritan” could assist someone with. LPA asked what was meant by “Good Samaritan”, O1 answered that a person acting in good faith to assist someone cannot not punished legally if there are adverse outcomes. O1 feels staff in the facility should act in that nature rather than calling 911 for “every little thing.”. S1 informed LPA staff are taught to call 911 every fall and for any situation they deem an emergency. S1 also informed LPA that staff are usually not informed when a resident calls 911 on his or her own nor does they facility request that residents inform staff before calling 911. S2 confirmed that staff in the facility are not clinically trained and would rather that staff err on the side of caution and call than to assist and further harm a resident in need, as S2 confirmed staff are trained to do. S3 greets individuals coming into the facility. S3 does not ask 911 responders for the reason they are coming in. S3 is usually aware that 911 was called, unless it was a resident. Continued on LIC9099-C Continued from LIC9099-C S4 is aware that at times residents have called 911 without staff being informed, but S4 has been instructed to not stop a resident from calling 911. S5 and S6 assist residents in the activities room. S5 and S6 say paramedics have never needed to stop a class to assist residents. S3, S4, S5 and S5 all told LPA that 911 is called, per facility policy, every time there is a fall and overtime the resident requiring assistance is deemed to need assistance beyond the scope of training that staff member has. R1, R2 and R3 all stated they had never called 911 on their own. R1, R2 and R3 all feel that staff and residents should be able to call 911 without seeking approval first. Based on interviews the above allegation is UNSUBSTANTIATED. 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. No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.