complaint·November 1, 2023

Allegation: Residents were left unsupervised while in care Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident records. Witness (W1) confirmed with LPA that on 10/31/23 at 4AM the fire department responded to a fire alarm which has been activated at the facility for 30 minutes. When fire responders arrived, they opened the front gate with a key and a resident opened the front entrance of the facility. Fire responders stated no staff was awake and on hand to actively supervise the residents. W1 stated they forced opened the office and called the administrator (ADM) who rushed to the facility and arrived around 5:30AM. Staff (S1, S2) were found by police and fire responders sleeping in their cars at the parking lot. Review of incident report dated 10/31/23 confirmed that staff (S1, S2) were asleep inside their cars at the parking lot while on night shift and were not inside the facility when the fire alarm was set off by a resident at 4AM. FIre alarm was blaring at the facility for 30 minutes and was deactivated by fire responders when they arrived at 5AM. ADM stated all residents were safe and no injuries were observed. ADM1 stated S1 was terminated 10/31/23 due to negligence and S2 was placed on unpaid leave while facility schedules mandatory in-service staff retraining on proper care and supervision of residents while on duty. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that residents were left unsupervised while in care was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.