Complaint·October 23, 2025

Investigation Revealed the Following: Allegation: Facility does not have sufficient staffing to provide care to residents. The details of the complaint alleged that it was observed that there are not enough staff during regular hours. On October 21, 2025, at approximately 1:00 p.m., during a records review, Licensing Program Analyst (LPA) Iniguez examined the facility’s Call-off Tracking Log for the dates of September 29-30 and October 1-3, 2025. The log indicated that the facility typically employs around 20 care staff members each day. According to the documentation, the highest number of staff callouts on a single day was five. This left approximately 15 care staff members on duty that day to provide care and supervision for the residents. On September 26, 2025, at approximately 10:00 a.m., during an Interview with the facility Administrator (A#1), he stated that we have sufficient staff to provide care and supervision for the memory care residents. However, there are days when we experience a high number of callouts from facility staff. This situation often requires some employees to work overtime and double shifts. Additionally, (A#1) mentioned that when there are call-outs, the remaining facility staff members covering for those absent are expected to meet the needs of the residents in their care. (A#1) also expressed that when staff members call out, he does not believe there is an immediate danger to the residents. On September 26, 2025, at approximately 11:00 AM, during an interview with residents (R#1-R#6), (6) out of (6) stated that the facility does not have enough staff to take care of them and the rest of the residents in care. Evaluation Report continues LIC 9099-C On September 26, 2025, at approximately 12:00 PM, during an interview with facility staff (S#1-S#6), (5) out of (6) stated that the facility does not have enough staff to provide care to residents. In addition, (6) out of (6) facility staff said that they feel the residents are not in immediate danger due to staffing issues; however, this can potentially become a problem since sometimes there are (1) caregiver per (20) residents with different care needs. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.