complaint·December 23, 2025

On 12/04/2025, LPA Huynh conducted a subsequent visit. Between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. During today’s visit, the LPA and AA conducted a physical plant tour at 9:45AM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff confines resident to their bedroom” It was reported that Resident #1 (R1) was confined to their bedroom and staff did not provide assistance with transfers to enable R1’s participation in community activities. Staff interviews revealed that R1 had limited mobility, was unable to sit independently, and required assistance with transfers. R1’s family specifically requested staff to assist with transfers so R1 could have social exposure, fresh air, and meals in the dining room. The family reportedly visited the facility daily and often completed transfers themselves, which limited opportunities for staff to assist. Despite this, staff acknowledged awareness of the family’s requests over previous months, but confirmed they were not accommodated due to R1’s need for full supervision when in a wheelchair. Staff further reported they were instructed not to assist R1 into the dining room for meals, without explanation. Staff noted R1 was only transferred out of bed two (2) to three (3) times per week for scheduled showers. Although R1 had a wheelchair restraint available to aid with sitting, staff declined to utilize it. Staff later stated that following the LPA’s initial visit conducted on 11/13/2025, facility staff began assisting R1 outside of their bedroom and into the community. The Department of Health Care Services Individual Service Plan (ISP) updated on 08/28/2025 documented that R1 should be supported to avoid social isolation. Staff were directed to encourage and assist R1 with escorting and reminders for activities to promote participation. The ISP also required staff to encourage R1 to engage in safe, independent activity whenever possible. Due to R1’s bed-bound status, unsteady gait and need for safe transfers, staff were expected to provide necessary support to ensure safety. Report Continued on LIC 9099-C Staff were also expected to assist with activities of daily living (ADLs) to promote movement and independence, and to facilitate interaction with other residents to foster social connection. Through these efforts, R1 was expected to maintain or improve their level of mobility. R1’s Physician Report dated 04/02/2025 confirmed R1 was non-ambulatory with motor impairment, utilized a wheelchair, and required assistance with transfers. Based on interview and record review, the facility did not assist or encourage R1 with mobility and social engagement. The preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided. On 12/04/2025, LPA Huynh conducted a subsequent visit. Between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. During today’s visit, the LPA and AA conducted a physical plant tour at 9:45AM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff did not respond to a resident’s call button in a timely manner” It was reported that facility staff failed to respond to a resident’s call button in a timely manner, with a response time of one (1) hour. Interviews with five (5) out of nine (9) residents indicated that while most do not frequently utilize their call button, staff response time generally ranged from immediate assistance to approximately twenty (20) minutes. In contrast, four (4) residents reported experiencing delays of up to one (1) hour, which they attributed to low staffing levels. Staff interviews revealed that response times vary depending on current tasks and simultaneous call button use, with an average response time between ten (10) minutes to twenty (20) minutes. Staff stated they prioritize requests based on urgency, ensuring completion of ongoing assistance before responding to other residents. Typical call button requests include showers, incontinence care, transfers, and obtaining items such as ice. One (1) staff reported the longest wait time was approximately forty-five (45) minutes when a resident requested a transfer. The ED explained that they will first check in with residents to determine the nature of their request before prioritizing assistance. The ED also noted that call button activity is typically low due to routine care being provided throughout the day. Additionally, Staff are required to verbally acknowledge call button activations via facility radios. LPA Huynh tested five (5) randomly selected resident rooms on the first and second floors. Call buttons were located at residents’ bedsides and in each restroom. All tested call buttons successfully triggered the call lights located in the med-tech room and activated the corresponding auditory alarm. Report Continued on LIC 9099-C During the investigation, the LPA observed staff acknowledging call buttons and responding to residents’ requests for assistance. Based on interviews and observation, there is insufficient evidence to determine whether staff failed to respond to resident call buttons in a timely manner. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Allegation: “Staff did not safeguard a resident’s personal item” It was reported that the facility did not safeguard R1’s hairbrush and was unable to locate it. Interview with staff revealed that the facility does not frequently receive reports of missing or stolen items. In most cases, residents reported items as missing that are later found within the bedrooms. Staff noted that residents with cognitive impairments often report missing items they did not possess. Staff further stated that they have generally been successful in locating and returning residents’ belongings when such reports are made. Facility practices for safeguarding personal property include ensuring resident doors are closed and locked, maintaining staff presence and supervision in hallways, and monitoring cameras positioned throughout the facility. When items are reported missing, staff assist in searching the facility, notifying administrators, and maintaining communication with the residents regarding the status of the search. Interview with the AA revealed that R1’s hairbrush went missing shortly after their admission to the facility. R1’s family mentioned the issue and the facility offered to provide a locked drawer for safe keeping of personal items as well as offered to replace the hairbrush. R1’s family declined the offer and stated they would replace it themselves and provided the AA photo documentation. During this time, it was reported that R1 received several visitors daily which included physical therapists and home health or hospice nurses who may have misplaced the item. R1’s family reportedly agreed. Report Continued on LIC 9099-C Interviews with six (6) residents revealed that they had not experienced missing or stolen personal items. One (1) resident reported towels missing after laundry service, which were later found and returned. Another resident reported missing items and stated that staff “did what they could” to assist in locating the items. Based on interviews and review of facility procedures, there is insufficient evidence to determine whether staff failed to safeguard R1’s personal item. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited related to the above allegations. Exit interview conducted. A copy of the report was reviewed and provided.