complaint·March 20, 2025

Investigation revealed the following: Allegation: Staff do not ensure facility fire alarm is in good repair. It is alleged that the fire alarm is broken and randomly goes off unexpectedly in the facility disturbing its residents. On 12/04/24 LPA Watson interviewed staff#1 – Staff#8 (S1-S8) regarding the allegation; Of those interviewed 8 out of 8 staff agreed to the allegation. On 12/04/24 LPA Watson interviewed residents #1-residents#8 (R1-R8); 8 out of 8 staff interviewed agreed with the above allegation. On 12/04/25 an Interview with the Executive Director Clifton Douyon revealed that the smoke detectors located in room 118 and 221 were dysfunctional and did not properly work and needed repair. The director explained that they sounded off intermittently because of construction work being performed on the facility ceiling. During the interview it was also revealed that the triggering of the second smoke alarm was due to rainwater from the roof top of the ceiling. On 12/05/04 LPA Troy Watson interviewed and toured the facility grounds with the Maintenance Director Glen Olano, LPA observed and confirmed that the smoke alarms needed repair and were not functional at the time of visit. LPA Watson also called and contacted Johnson Controls multiple times to verify the estimated time of arrival of the replacement parts and installation of the smoke alarms, but no confirmation of parts ordered or an estimated time of arrival for repairs could be verified. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Therefore, the allegation according to the California Code of Regulations (Title 22, Division 6, Chapter 8) has been Substantiated . The following deficiencies have been observed and a citation issued (ref. LIC 9099) An exit interview was conducted with the Executive Director, Clifton Douyon and a hard copy of this report was provided.