complaint·May 23, 2025

The investigation revealed the following: Allegation-Staff did not provide adequate supervision to resident(s) in care. The details of the complaint alleged that an alarm was going off in a resident’s room from 9:00am -9:25am on 05/19/25, but no one came to see what the problem was or if the resident was in danger or needed care. On 5/23/25, from 10:00am-2:00pm, the department interviewed staff (S1-S7) and residents (R1-R6) regarding the allegation. 6 of 7 staff denied the allegation that the Staff did not provide adequate supervision to resident(s) in care. All staff stated that all residents are provided with adequate supervision and if assistance is needed, residents have the option of using the call buttons in their room, pendants, or the motion sensors would alert staff that the resident needs assistance. One staff was aware that room 302B was having problems with the emergency pull chord device. The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed denied the allegation that Staff did not provide adequate supervision to resident(s) in care. The majority of residents interviewed stated that the staff are meeting their needs and are satisfied with the care and supervision they are receiving at the facility. The Department toured room 302B and pulled the emergency pull chord, the light was flashing, but no one came to assist. The department observed the reason no one came to assist was because the signal system was not transmitting an auditory signal to the care staff. The department reviewed the Resident Incident Details Report (Dated: 05/18/2025-05/24/2025) and observed that on 05/19/2025 between 7:02am-09:23am the device was in motion but was not communicating with staff. The staff provided the department with a work order (Dated: 05/23/2025) for room 302B to address the pull chord and verify that the connection is working. Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not provide adequate supervision to resident(s) in care, is found to be Substantiated . The emergency pull chord in the resident’s room was not working and poses a potential health and safety risk. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations that are not cleared by the due date of 06/13/2025 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiencies are issued and plans of corrections were discussed. An exit interview was conducted with Fabiola Marciano, Executive Director, and a hard copy of this Complaint Investigation Report was provided.