Complaint·January 28, 2026

CONTINUE FROM LIC 9099 Allegation: Staff left resident soiled for an extended period of time. Investigation Finding: substantiated. R1 reported using the facility provided pendant to request assistance, R1 stated that R1 calls the front desk during daytime hours. R1 stated that R1 was left soiled for more than three hours. Staff member S3 reported responding to R1 but indicated that staff member S2 who was on duty did not respond to assist. During the investigation, S2 confirmed being on duty but acknowledged not responding to R1. Interviews with S2 revealed that two caregivers and one medication technician were assigned during the NOC shift; however, S2 stated that S2 was not assigned to R1 and was working on the opposite side of the building. S4 reported that staff are required to conduct routine rounds and change residents every two hours or as needed. Based on the evidence obtained this allegation is SUBSTANTIATED. Allegation: Staff did not answer resident's call button in a timely manner. Investigation Finding: substantiated. R1 reported that staff did not respond to the call pendant in a timely manner, resulting in the resident remaining soiled for several hours. R3 reported that call pendants were not functioning and stated they had been without a pendant for five days. R3 also reported that the facility is occasionally short staffed, particularly during the NOC shift, resulting in prolonged wait times for assistance. R4 reported that only three staff member are assigned during the NOC shift and that if R4 falls three staff members are required to assist R4 to get up. An interview with staff member S4 confirmed ongoing issues with the pendant system. S4 also reported that staff complete routine rounds to check residents for assistance needs. Based on the evidence obtained this allegation is SUBSTANTIATED. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided.