Complaint·December 22, 2025

This report supersedes the report created 9/23/25 and the findings will remain unchanged. 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 1:00 p.m., Licensing Program Analyst (LPA) Iniguez reviewed the facility’s Call-off Tracking Log for September 29–30 and October 1–3, 2025. The log showed that the facility typically schedules 30 care staff per day, with a maximum of 5 callouts per day, resulting in 25 staff available for care and supervision. On December 22, 2025, at 10:00 a.m., LPA Iniguez also reviewed Functional Capabilities Assessments (LIC 9172) for 56 residents, aged 67 to 97, whose care needs range from independent to requiring extensive assistance. The daily staffing schedule includes 9 caregivers, 3 medication technicians, and 1 LVN during the AM shift (13 staff); 8 caregivers, 3 medication technicians, and 1 LVN during the PM shift (12 staff); and 7 caregivers with 1 medication technician during the NOC shift (8 staff). This totals 24 caregivers, 7 medication technicians, and 2 LVNs, for a total of 33 staff per day. Based on this review, the facility maintains adequate staffing to meet the care and supervision needs of all 56 residents, even on days with the highest callouts. With approximately 25 care staff for 56 residents, the staff-to-resident ratio of about 1:2.2 exceeds minimum standards and is appropriate for a population with mixed acuity, provided staff are properly trained, and tasks are well organized. Evaluation Report continues LIC 9099-C This report supersedes the report created 9/23/25 and the findings will remain unchanged. 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. 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. Evaluation Report continues LIC 9099-C This report supersedes the report created 9/23/25 and the findings will remain unchanged. 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.