complaint·December 12, 2025

In regards to the allegation that " Staff did not assist resident in a timely manner resulting in resident sustaining a fracture," it is alleged that R1 sustained a fall on 7/5/2025 and fractured their wrist, and that staff did not assist them in a timely manner. During interviews with residents, seven (7) out of eight (8) did not corroborate this allegation. Some residents indicated that they have not been assisted in a timely manner by the staff at the facility, however they explained that they did not sustain any fracture in any of these incidents. During interviews with staff, none of them corroborated the allegation. One staff member explained that they were aware that R1 had fallen, and that they offered to take them to the hospital however they refused. Another staff member also indicated that R1 refused to be taken to the hospital, and therefore facility staff scheduled an appointment for R1 to be see their doctor on 7/9/2025. Records reviewed shows that on 7/11/2025 R1 was referred for an x-ray which revealed the fracture and was then ordered to be placed in a splint for the healing of the broken bone. In regards to the allegation that "Staff did not seek medical attention in a timely manner," it is alleged that R1 reported that they had fallen on 7/5/2025 to S5, however they never reported the injury to the administrator or any other staff. During interviews with the residents, six (6) out of eight (8) did not corroborate the allegation. One resident stated that they have not had issues with obtaining timely medical care while living in the facility. Another resident also stated that they haven't had problems obtaining medical care when they need it. During interviews with staff, none of them corroborated the allegation. The administrator stated that they became aware of the incident on the day that it occurred by other staff, and offered medical assistance to R1. Another staff interviewed stated that all staff were aware of the fall and did seek medical attention for R1. An SIR dated 7/5/2025 indicated that administrator and staff were aware of the fall and attempted to obtain medical assistance for R1 however they refused. In regards to the allegation that " Staff yell at resident," it is alleged that S5 has screamed at R1 in the facility in the past. During interviews with residents, six (6) out of eight (8) residents did not corroborate the allegation. One of the residents interviewed stated that they believe that S5 is a fair caregiver and is nice. Another resident stated that they have never witnessed staff yell at the residents in the past. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that they have never heard S5 or any other staff raised their voice at residents in the facility. LPA attempted to interview S5, however they have since stopped working at the facility. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided. In regards to the allegation that there is " Insufficient Staffing," it is alleged that residents have waited for over an hour to be assisted by caregivers in the facility. During interviews with the residents, six (6) out of eight (8) corroborated the allegation. One of the residents interviewed stated that they have had to wait half an hour or more to be assisted by staff members at the facility after requesting assistance through their call light. Another resident interviewed stated that it has taken a long time to be assisted by staff particularly in the night shift. During interviews with staff, none of them corroborated the allegation. One staff member stated that during the morning shift they have two (2) caregivers and two (2) med techs on schedule, in the afternoon it is two (2) caregivers and one (1) med tech, and at night it is one (1) caregiver and one (1) med tech. Another staff member stated that they are not short staffed and that they have caregivers and med techs fill positions as needed if a staff were to call out. Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED . California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D page. Exit interview was held and a copy of the report along with the appeal rights were provided and will be emailed to the administrator.