Complaint·March 20, 2026

On the allegation " Facility is in disrepair" on 8/27/2025 LPA inspected a random selection of residents rooms. LPA observed that residents personal pendents are having issues notifying staff when pressed and ED as well as the HSD confirmed that there is a dead zone for rooms 201-204 as well as rooms 243 and 241 which they were actively trying to get resolved. At the time of the visit the pendents were not working and were in disrepair therefore the allegation Facility is in disrepair is substantiated. On the allegation "Facility is not adequately staffed" LPA conducted interviews on 3/20/2024 with residents as well as reviewed staffing available for the month of August 2025. LPA interviewed R1, R2, and R3. All residents stated that they feel that there is not enough staffing and that they have had trouble with getting assistance in a timely manner as a result. R1 stated that the facility has had issues with staffing and high turnover. R2 stated that they notice staffing is short especially on the weekends and that they have been told that they will have to wait longer due to the shortage. R2 also stated that there are sometimes only 2 staff for all of assisted living (AL) R3 stated that when they press their pendant to get assistance it can take a really long time due to the shortage of staff. LPA observed that on 8/24/2025 there was only 1 caregiver and 1 medtech available in AL from 6am- 2pm. Originally 2 caregivers were scheduled however 1 called out. On 8/24/2025 the census was 56 in AL and 31 in memory care (MC). Memory care typically has at least 5 caregivers on shift. Therefore the allegation "Facility is not adequately staffed" is substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted with Executive Director, San Sor. Appeal rights and copy of this report provided. On the allegation "Facility left residents unattended" LPA reviewed schedules and was unable to identify a time when there were no staff available to residents. Through interviews the LPA did identify that there have been times where staff were insufficient however LPA did not observe that zero staff were present therefore the allegation "Facility left residents unattended" is unsubstantiated. On the allegation "Facility did not ensure residents receive meals as scheduled" LPA conducted interviews with residents and reviewed staffing schedules and was unable to identify a time when the Facility did not ensure residents received meals as scheduled. All residents interviewed state that they have always gotten their meals within their time frames or went down to dinning, therefore the allegation is unsubstantiated. On the allegation "Residents needs and services are not being met" LPA conducted interviews with residents and reviewed care plans. LPA also reviewed previous complaints and identified that due to pendent malfunctions residents were left soiled for prolonged periods of times however LPA will not recite because it was already addressed on complaint 15-AS-20250731111939. LPA did find during their interviews that residents had to wait longer for their needs and services to be met however they did still receive the care therefore the allegation Residents needs and services are not being met is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . A copy of this report provided.