Complaint·April 9, 2026

This report supersedes the report created 12/22/25 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 obtained and reviewed the facility’s Call-off Tracking Log for September 29–30, 2025 and October 1–3, 2025. The department found that the facility schedules on average approximately (33) care staff per day. The facility experiences on average, approximately (5) staff callouts, and this results in an average of approximately (28) staff per shift are available to provide care and supervision. On December 22, 2025, at 10:00 a.m., LPA Iniguez obtained and reviewed Functional Capabilities Assessments (LIC 9172) for 56 residents and found their care needs range from independent to requiring assistance. Based on the daily staffing schedules (Dated) reviewed, the department found (9) caregivers, (3) medication technicians, and (1) LVN are working the AM shift. The department found (8) caregivers, (3) medication technicians, and (1) LVN are working during the PM shift. The department found (7) caregivers and (1) medication technician working during the overnight shift. The department found sufficient staffing to support the needs of the residents are present for each shift. 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. Evaluation Report continues LIC 9099-C This report supersedes the report created 12/22/25 and the findings will remain unchanged. 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. 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 Esperanza Naaktgeboren/Administrator.