Complaint·March 17, 2026

Allegation: Staff are not responding to residents call button. It is being reported that it takes staff up to 2 hours to respond to the resident’s call button. LPA Felisa Shirley interviewed S1 on 3/17/26, S1 stated that when call button alerts are received, responding staff calls the caregiver assigned for residents in that specific area on the walkie in which the alert was received. Per interview with S1, if there is a shortage of staff, if there is an alert from a resident, she sometimes identify the resident on the alert panel and responds to the alert herself to help out. Per interviews with S1-S6, there is no tracking system in place to verify response times for call button alerts from residents. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 8 (R1 – R8). Of those who interviewed 2 out of 8 denied the allegation. Two residents confirmed the allegation, and 4 residents neither denied nor confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not responding to residents call button,” therefore, the allegation is unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Sheila Sikula. Allegation: Staff did not administer medication to residents in care. It is being reported that R1 stated that medication administration is timely, but the total daily dose is inconsistent. Per review of March 2026 Medical Administration Record, the (MAR), LPA Shirley observed that as of 3/17/26, R1 has 28 active medications and 10 PRN’s. Records revealed that the medication, Pantoprazole does not have initials on 3/16/26 for the a.m. dose and the pill is missing from the bubble pack. LPA Shirley also observed on 3/17/26 there is no initial for the a.m. dose and the pill is still in the bubble pack. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 8(R1 – R8). Of those who interviewed 7 out of 8 denied the allegation. One resident confirmed the allegation. According to the information gathered there is sufficient evidence to support the allegation “Staff did not administer medication to residents in care”. Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued and an exit interview is conducted with the Wellness Director, Sheila Sikula. A copy of this report and appeal rights were provided.