complaint·August 19, 2025

Allegation#1: Facility has no activities director. It was alleged that the facility has no activities director. Interviews with the facility staff including executive director (S1), business director (S2), and activities director (S3) and other facility staff revealed that the current activities director has held the position since November 2024. A review of staff roster and personnel files for the last few months and of the staff list confirmed S3 has been the activity director. Interview with S3 at 2:20 PM on 4.23.2025 confirmed they are and have been the activity director. Residents interviewed during investigation also verified that the facility has activity director. A review of S3’s personnel record verified the information revealed from interviews. Based on observation, interviews and record review, the facility has an activity director. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Allegation #2: Facility does not have an administrator. It was alleged that the facility administrator was fired and no facility representatives from management were available to report to. During investigation LPA observed Executive Director (ED) (S1) and other administrative personnel present and available in the facility. Interview with S1 and S2 at 2:47 PM on 04/23/25 revealed that they were hired 3 days ago. Prior to hiring of new ED, Business Office manager (S2) was acting Executive Director and has been in charge of the facility. Interviews with Resident Service Coordinator (S8) and other facility personnel revealed that in the absence of ED, there are always someone designated to act as an Administrator. All staff including administrative personnel were trained to report any concerns and incidents to S2 or other designee. Interviews with eleven (11) out of fifty-eight (58) residents revealed that management is always seen at the facility assisting staff and residents as needed. A review of staff roster and personnel records verified the information revealed from interviews. Based on observation, interviews and record review, although the ED is not always present at the facility, the facility ensured that a qualified designee is always present and available to manage facility staff and assist families and residents as needed. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Continue to LIC 9099-C Allegation #3: Licensee has not conducted emergency drills. It was alleged that the facility has not conducted an emergency drill ever. ED and other managers indicated they have a contract with the Southwest Fire Life Safety and Security and just conducted the emergency fire drill on 04/23/25 in the morning. Staff stated there are always one to two full-time staff members who will work with the agency staff in the overnight shift. When they have any fire or disaster drills, the facility staff on the shift and temporary agency staff present in the facility are participating during the drill. In the event of any emergency, staff know where to obtain the emergency contact numbers and LIC610E Emergency Disaster Plan. During facility inspection LPA observed the emergency disaster plan posted and a Fire and Disaster Guidelines binder by the S2 office. Residents interviewed during investigation did not address any concerns regarding emergency disaster drill. Residents feel that there are sufficient well trained staff to assist residents during emergencies. A review of the facility records verified that facility is conducting quarterly emergency drills as required. Based on observation, interviews, and record review, there is no sufficient information to verify validity of the complaint. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit Interview conducted. Copy of report provided to ED.