complaint·November 13, 2025

Allegation: “Staff do not ensure resident has access to call button/pendent.” Observations revealed the following: On 11/07/2025, residents’ bedrooms and bathrooms in unit 1 had call buttons with a long string on the wall. On 11/13/2025 around 10:30 AM, room 404 did not have a call button with a long string on the wall, furthermore, S1 and Staff 8 (S8) searched R1’s room for the said call button and S8 found said call button in drawer. On 11/13/2025, S8 screwed the call button on the wall next to R1’s bed. Interviews conducted on 11/13/2025 revealed the following: R1 indicated that they did not know where call button was located; Staff 6 (S6) indicated that R1’s call button fell and they had their call button on their bed next to them; S1, Caregiver Supervisor morning shift and S7, Caregiver Supervisor evening shift both indicated that they were not informed that R1’s call button fell from the wall. Substantiated: Based on observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.