complaint·September 5, 2025

During the interviews with staff, all staff stated yes, the door is locked, however, there is someone in the office to let residents out twenty-four (24) hours a day, seven (07) days a week. Staff added there are alternate doors for residents to use in the event of an emergency. Upon arrival today, LPA Duguma observed two (02) residents in front of the building. As LPA was about to approach what appeared to be the main entrance to the facility, the two (02) residents gestured towards the office entrance and stated, "you have to go in and out through there". During the tour LPA observed the exit door all residents are using to enter and exit the building is equipped with a digital locking mechanism and marked OFFICE. LPA did note other exits in the facility that are delayed egress with alarms but not used as main entrances and exits which could pose a potential health, safety and personal rights risk to residents in care should they rely on muscle memory in the event of an emergency such as a smoke filled section of the building. After bring this to the Administrator's attention, facility immediately removed the digital locking mechanism from the OFFICE door and began using the double doors at the front of the building for residents to enter and exit the facility. Based on interviews and observations, there is enough information to verify the allegation, therefore the allegation is SUBSTANTIATED at this time. A plan of correction was not issued at this time as the facility took corrective measures in the presence of the LPA. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.