complaint·January 10, 2026

Regarding the allegation: Staff does not answer resident's call button in a timely manner. It was alleged that staff have not responded to R1’s call button and have left them waiting for an excessive amount of time. To investigate the allegation, LPAs conducted interviews with nine (9) residents and five (5) staff members. Interviews with six (6) of the nine (9) residents stated they have used their call-button and have had no issues with staff not responding. LPA’s interviews with R4, R7 and R10 revealed that they have not had to use their call-button, as of yet. LPA’s interview with R1 (who was observed to be alert at the time of the visit) revealed that when they ask for help from staff, they do come and it takes them, “10 to 15 minutes” to arrive. LPA’s interview with all five (5) staff members stated that staff respond to residents’ call alerts in a timely manner. During LPAs physical plant tour, LPAs pressed on R1’s pendant where staff were observed to arrive promptly. Based on interviews and observations there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not allow resident access to call button. It was alleged that R1’s call button was kept inaccessible from them by staff. To investigate the allegation, LPAs conducted interviews with seven (7) residents and five (5) staff members. LPA’s interviews with all residents revealed that they have access to their call-buttons. LPA’s interview with four (4) of the five (5) staff members confirmed that they have not kept residents’ call-buttons inaccessible nor have they witnessed that to be done. During LPA’s physical plant tour, LPAs observed R1 to be wearing their portable call pendant around their neck to which they then pressed to call for help from staff. However, LPAs witnessed R1’s call-button cord to appear tangled and knotted. LPAs questioned S7 as to why R1’s cord was tangled to which they could not provide an answer and were unsure of themselves. LPA Segovia’s record review of R1’s staff shift notes, documented R1 was visited on 3/26/2025 by Sheriff, Alejandro. Documentation revealed Sheriff Alejandro stating R1 had their pendant on their person. Based on interviews and observations, the allegation may have occurred, however there is not a preponderance of evidence to prove the alleged allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff not meeting residents needs. It was alleged that R1’s needs were not being met by staff. To investigate the allegation, LPAs conducted interviews with ten (10) residents and four (4) staff members. LPA’s interview with all ten (10) residents revealed that their needs are met, such as but not limited to: showers, food and wheelchair assistance. LPA’s interviews with all four staff members confirmed that they help residents with their needs. LPA Segovia’s interview with S5 revealed that if a particular resident needs help with their food being chopped, they assist. LPAs interview with R1 stated that staff come to assist them when needed. During LPAs physical plan tour, LPAs observed R1 being assisted by two (2) staff members. Based on interviews and observations, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not ensure resident's showering needs are being met. It was alleged that R1 was not given their required showers of two times a week. To investigate the allegation, LPA Segovia conducted a record review of R1’s file. LPA’s review of R1’s re-assessment dated 3/01/2025, revealed R1’s bathing requirements were documented to be provided by a third-party provider. Further record review revealed the third-party provider to be R1’s Hospice agency. On 9/25/2025, LPA Segovia requested R1’s medical records from the Hospice agency. LPA Segovia’s record review of R1’s Hospice Aide visits dated 1/26/2025 to 3/21/2025 confirmed R1’s showering needs were met twice a week and documented per visit. Based on record review of R1’s showering needs being met by the Hospice agency, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure resident was properly secured in wheelchair. It was alleged that staff did not properly secure R1 in their wheelchair resulting in them falling more than once. To investigate the allegation, LPA Segovia conducted record review. LPA Segovia’s record review of R1’s Hospice Aid visits dated 1/26/2025 to 3/21/2025 documented R1’s wheelchair to have been used for ambulatory purposes. Further record review of the facility’s staff notes documented occurrences of when R1 had fallen due to them not waiting for their two-person assistance as documented by their Functional Evaluation plan. During LPA’s physical plant tour on 4/01/2025, R1 was observed to be positioned up-right in their wheelchair. LPAs observed R1 to be seated and did not observe any signs of R1 not to be secured correctly to their wheelchair nor observed R1 to fall from their wheelchair. Based on record review and observations, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff does not ensure resident is receiving physical therapy. It was alleged that R1 did not receive their required Physical Therapy. To investigate the allegation, LPA Segovia conducted record review where it was revealed that on 2/04/2025, the facility contacted Hospice inquiring about R1’s status for Physical Therapy, where they were informed (by Hospice) that they would be following up and be in contact with R1’s family. Based on record review, that the facility contacted R1’s Hospice regarding R1’s Physical Therapy, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not communicate with resident's responsible party. It was alleged that R1’s Responsible Party had not been promptly contacted when R1 became ill with a communicable or infectious disease. To investigate the allegation, LPAs conducted interviews with seven (7) residents. LPA’s interviews with all seven (7) residents confirmed that the facility communicates with their responsible parties. LPA Segovia’s record review of the facility’s Unusual Incident/Injury Report (SIR) revealed the facility had self-reported to Community Care Licensing Division (CCLD), where it was documented that R1’s Responsible Party and Hospice were both notified regarding R1’s recent illness dated 3/07/2025. Additional record review of Resident’s Notes documented that R1’s illness was disclosed to R1’s Power of Attorney (POA) on 3/07/2025. Further record review of R1’s Hospice file showcased Physician Orders to treat R1’s communicable or infectious disease were ordered 3/07/2025. Based on interviews and record review, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not ensure resident's room is clean. It was alleged that R1’s room was not clean. To investigate the allegation, LPAs conducted interviews with nine (9) residents. LPA’s interviews with all residents confirmed their rooms are cleaned by staff. LPAs interview with R1 revealed that their room is cleaned every day. During LPAs physical plant tour, LPAs tour of R1’s bedroom was observed to be neat, clean and organized. LPAs did not observe trash on the floor. LPAs did not observe any foul odor to have been present. Further tour of resident’s room revealed the rooms to be clean and in proper condition. Based on interviews and observations, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Health and Wellness Coordinator.