Complaint·May 4, 2026

The investigation revealed the following: 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. Per LPA Felisa Shirley’s observation, the resident call system is stationed in 2 locations within the facility, one place is in the med tech room and the second is in the 3 rd floor dining room. LPA Shirley interviewed S1 on 3/17/26, S1 stated that when call button alerts are received, receiving staff uses the walkie to dispatch the caregiver assigned for residents in that specific area on the walkie and the responding caregiver is immediately notified of the resident’s location. LPA Shirley toured the facility and pushed the call button in R1’s assigned room at 10:01am and noted that it took receiving staff 3 minutes to respond and arrived at R1’s room at 10:04am. Per interview with S1, if there is a shortage of staff when an alert comes in from a resident, she sometimes identify who the resident is 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 deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to, Azucena Reyes, Administrator. 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) on 3/17/26, LPA Felisa Shirley observed that as of 3/17/26, R1 has 28 active medications and 10 PRN’s. On 3/17/2026, LPA Shirley reviewed the MAR for R1 and noted that for the date of 3/16/2026, MAR had no initials for pantoprazole, however, the medication was not in bubble pack. For 3/17/2026, MAR had no initials for pantoprazole AM dose and medication was 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 Azucena Reyes, Administrator . A copy of this report and appeal rights were provided.