complaint·January 9, 2026

Regarding the allegation “Staff are not answering facility phones,” it is being alleged that residents families are not able to get a hold of the residents in the facility. Records review revealed the following: Although records show that the facility has implemented improvements, including installing a better phone system and conducting staff training with signed acknowledgment forms, residents’ families are still having trouble reaching their loved ones by the facility phone. Observations revealed: On 10/23/2025, LPA observed staff answering calls but noted limited knowledge of transferring calls to the Memory Care unit and no documented training on the new phone system. While calls were observed being answered during the visit, evidence indicates that prior to corrective actions, staff were not consistently able to answer or properly route calls, which negatively impacted residents’ ability to maintain personal relationships and receive calls from family members or emergency contacts. As a result, a Type B deficiency was cited under Title 22 §87468.1(a)(2) (see LIC809 & LIC809-D). On 01/09/2026, additional interviews were conducted and revealed the following: Staff interviews (S1–S9) revealed that nine staff disagreed with the allegation while two staff (S10-S11) agreed. Resident and family witness interviews revealed mixed feedback, with the majority agreeing that calls were not consistently answered. Two residents (R1–R2) and six family witnesses (W1–W6) reported difficulty reaching staff, while five family witnesses (W7–W11) reported no issues. One family member stated that in 2024, reaching staff was a “huge problem,” and although conditions improved in 2025, issues persisted intermittently. Although the facility has taken corrective actions to improve phone accessibility, residents’ families continue to report difficulty reaching their loved ones. Based on the evidence gathered, records reviewed, observations, and interviews conducted, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is being issued on the attached (LIC-9099D). An exit interview, a copy of this report, and appeal rights were provided to the Administrator.