complaint·April 1, 2026

Record reviews have revealed the following: Employee list indicates that all seven (7) PM shift and four (4) NOC staff remain active and are still working at the facility. Interviews have revealed the following: four (4) out of five (5) staff (S1-S4) and five (5) out of seven (7) residents (R1-R3 & R6-R7) have not agreed with the allegation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not respond timely to residents' requests for assistance”, it is being a lleged that because there are not enough staff, the staff cannot respond in a timely manner to chimes from residents seeking assistance. Record reviews have revealed the following: Employee list indicates that all seven (7) PM shift and four (4) NOC staff remain active and are still working at the facility. Interviews have revealed the following: four (4) out of five (5) staff (S1-S4) and six (6) out of seven (7) residents (R1-R6) have not agreed with the allegation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Licensee dissuades staff from reporting to Licensing”, it is being alleged that administration will fire any staff who report complaints to Licensing. Record reviews have revealed the following; EFA contains the following documents: Personnel Action Form (indicates that all staff are to be trained in emergency situations and how to respond with residents), Equal Employment Opportunity (EEOC) Employee Notification (indicates all protected categories of staff and that retaliation is prohibited), Statement acknowledging Requirement to Report Suspected abuse of Dependent Adults and Elders (SOC341) that indicates that all hired staff are included as "Mandated Reporters" which include "Reporting Responsibilities and Time Frames" and Employee Rights which indicate that, "No employer shall discharge, demote, suspend or threaten to discharge, demote or suspend, or in any manner discriminate against any employee for taking any of the following actions: (1) Making an oral or written complaint against the employer to the CDSS...having statutory responsibility for enforcement of the law...for the violation of any licensing law or other laws... . Interviews have revealed the following: four (4) out of five (5) staff (S1-S4) and all seven (7) residents (R1-R7) have not agreed with the allegation. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Maria Galvan - Executive Director (S1), and a copy of this report has been provided.