complaint·July 30, 2025

The investigation revealed the following : Allegation #1- Staff are not meeting resident's needs due to lack of staff. The details of the complaint alleged that residents are not getting proper care due to the lack of staff in the facility. It was reported that residents are not being bathed and that meals are not served in a timely manner. On 7/30/25, from 10:00am-3:00pm, the department interviewed staff (S1-S7) and residents (R1-R7) regarding the allegation. 5 of 7 staff denied the allegation that the Staff are not meeting resident's needs due to lack of staff. The majority of the staff interviewed stated that the staff were providing enough care to meet the needs of the residents. They stated that each resident has a service plan in place that provides different dates to bathe or shower the residents. They also stated that there haven’t been any complaints of residents not getting their meals in a timely manner. The department interviewed residents (R1-R7) about the allegation and 5 of 7 residents that were interviewed stated that there is enough staff to meet their needs. They also state that they do receive their meals in a timely manner and that staff does assist them with their ADLs when needed. The department reviewed the Personnel Roster (Dated: 06/03/2025) and observed that there is sufficient staff the meet the needs of the residents. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not meeting resident's needs due to lack of staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation #2- Staff do not seek medical attention for residents. The details of the complaint alleged that staff would avoid calling 911 when a resident might need medical attention, such as when they may fall in the facility, to avoid any issues. On 7/30/25, from 10:00am-3:00pm, the department interviewed staff (S1-S7) and residents (R1-R7) regarding the allegation. 7 of 7 staff denied the allegation that Staff do not seek medical attention for residents. All staff (S1-S7) that were interviewed stated that whenever a resident needs medical assistance or needs to go to the hospital, emergency medical services are provided. They also state that any of the staff can call 911 for assistance if the resident needs emergency services, no one is denied the right to have emergency services come out to the facility. Staff stated that at no time has anyone been told not to call 911 for help . Report Continued On LIC9099-C The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that staff does call 911 for residents if they need assistance and that they are satisfied with the care and supervision provided by the staff. The Department reviewed Incident/Injury Reports (Dated: 07/22/2025,06/13/2025, 06/16/2025, 07/05/2025) and observed that the facility has consistently reported incidents in the facility and requested emergency services to come out to the facility to assist with residents’ injuries. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not seek medical attention for residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation #3- Staff leave residents soiled for extended periods of time. The details of the complaint alleged that due to lack of staffing, the residents that are incontinent, are not being changed timely and are left in soiled briefs for an extended period of time. On 7/30/25, from 10:00am-3:00pm, the department interviewed staff (S1-S7) and residents (R1-R7) regarding the allegation. 7 of 7 staff denied the allegation that Staff leave residents soiled for extended periods of time. All staff (S1-S7) interviewed stated that they have not observed any residents who were not changed or were left in soiled briefs because of a lack of staffing. They state that they have enough staff to meet the needs of the residents and that their resident census has decreased. They state that they have two care givers and one med-tech per floor to care for the residents. The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that they had no knowledge of any resident who were left in soiled briefs for an extended period of time. They also stated that they were satisfied with the care and supervision provided by the staff. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff leave residents soiled for extended periods of time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Report Continued On LIC9099-C Allegation #4- Staff did not ensure facility's plumbing was in good repair. The details of the complaint alleged that the facility has plumbing issues that leave the residents without drinking water. It was reported that plumbers are always at the facility fixing something. On 7/30/25, from 10:00am-3:00pm, the department interviewed staff (S1-S7) and residents (R1-R7) regarding the allegation. 7 of 7 staff denied the allegation that the Staff did not ensure facility's plumbing was in good repair. All staff (S1-S7) interviewed stated that at no time has there been an issue where residents could not receive drinking water. They state that residents have access to bottled water throughout the building as well as drinkable tap water, if needed. Staff also stated that on January 28, 2025, there was an issue with the plumbing that needed the Department of Water and Power to come out for essential maintenance and repairs to maintain a backflow prevention device. They stated that the repair took place between 6am -11pm and the residents and their family members were notified on January 15 th and January 23 rd of the pending repairs. They stated that at no time were the residents impacted by the repairs. The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that they have never been without drinking water. They also state that they see plumbers around fixing things, but it hasn’t impacted their care. The Department reviewed the Maintenance Notes/Invoice (Dated: 01/28/2025, 01/13/2025, 01/23/2025) and observed that the facility alerted the residents to the pending repairs that would take place on January 28, 2025. The department also observed that the repair was completed on January 28, 2025. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not ensure facility's plumbing was in good repair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Johanna Dejoya Bellomo, Business Office Director, and a hard copy of this Complaint Investigation Report was provided.