Complaint·January 27, 2026

Two of the residents stated there were times when they pressed their call button and it takes time for the staff to respond. One of these residents stated when his Home Health nurse pressed the call button for assistance to change his clothes, the nurse end up changing and took 30 minutes for the caregiver to respond and at that time he was already in the dining room. On January 7, 2026, resident (R5) pressed the call button and the caregiver assigned did not respond. LPA interviewed the assigned caregiver who stated she was assisting another resident at the time R5 called for assistance and she didn't attend to R5 nor called her partner caregiver to check R5. On January 27, 2026, one of the staff interviewed stated seeing reports where resident fell at night and no caregiver responded. Based on information gathered, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan of correction were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Allegation: Due to lack of staff, residents have had multiple falls. Unusual Incident Reports submitted by the facility from July 2025 to January 20, 2026 pertaining to fall incidents were reviewed of which showed mostly were un-witnessed. All the staff interviewed stated they don't feel there's staffing issues. One of these staff stated staffing is good but more is better. Five residents interviewed stated they don't feel staffing is an issue. Therefore, the allegation is unsubstantiated. Allegation: Staff do not check on residents every 2 hours. Two of the staff stated residents in Memory Care are on two hour check throughout the day. Another staff stated the care providers are not required to check the residents in Assisted Living every 2 hours, and that the 2 hours checking is based on situation and should be on the Care Plan. All residents interviewed including one whose spouse is also In Memory Care stated they are not on every 2 hour check. Therefore, the allegation is unsubstantiated. Based on interviews and records reviews, the allegations are unsubstantiated. A finding that the complaint is 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. No deficiency cited. Exit interview conducted and copy of this report provided.