complaint·October 14, 2025

Allegation: Staff falsified residents' signature. It is alleged that resident (R1's) signature was falsified on "Release of Resident Medical Information" and "Consent for Emergency Medical Treatment.." The complaint alleges that staff falsified their signature so that the resident was able to be seen by the in-house physician, as well as that a med-tech staff falsified R1's signature stating the resident was given their medications on 12/24/24. According to the complaint, R1 was not at the facility on (12/24/25), the date medications were allegedly given to the resident. Staff interviewed denied the allegation. Record review of forms: "Release of Resident Medical Information" and "Consent for Emergency Medical Treatment" did not indicate there was signature falsification because they were electronically signed by R1 on 11/7/24 via Dropbox Sign. However, on 12/24/25, the facility filled out a Medication Release form. Resident (R1's) signature on that date was compared to other document signatures. The signature appears different and inconsistent with the majority of signatures on record. Copies of the Medication Release forms were obtained. There is sufficient evidence to support the allegation. Allegation: Staff does not ensure facility is in good repair. The complaint alleges the facility surveillance cameras are inoperable. According to information obtained, residents had an understanding the facility has surveillance cameras for their safety. However, in recent months many of the cameras have not been working. A total of 14 residents were interviewed, all the residents interviewed had knowledge of video surveillance in the building. However, the majority of the residents stated they do not know whether all the cameras are operable. Staff interviews confirmed that there are exterior cameras throughout the property, and that the majority of the interior cameras were removed. LPA observed one (1) surveillance camera in the hallway by the lobby area. Executive Director stated the camera video does not show on the main office monitor, and at this time only 3 cameras are displayed in the office surveillance monitor. Based on observation, the facility has multiple cameras, of which only 3 are showing as operable as of today. Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . An exit interview was conducted with Executive Director Jacqueline Cortez. A copy of the report and appeal rights were issued. Allegation: Staff are not adhering to job duty. The complaint alleges that night shift staff have been observed sitting in the main office asleep resting their heads down on the desk after they conduct their rounds. According to information obtained, the staff set alarms to wake up and continue with their rounds, and once they finish doing their rounds they go back to sleep. It is alleged that staff tend to sleep between 12 AM - 4 AM. Based on eight staff interviews, the findings indicate that there is a total of 3 night shift caregiver staff, 2 night shift med-techs, and a receptionist that works from 3:30 PM - 12:00 AM. Caregiver staff are in the main office or break room and med-tech staff are located in the medication room. According to staff interviews, caregivers are required to attend to residents in care and do 2 hourly checks at night. Med-techs pass out medications, respond to incidents and/or emergencies, and organize medications. Two (2) out of the eight (8) staff stated sometimes night shift caregivers do put their head down on the desk, but they are not asleep. A total 14 residents were interviewed. Two (2) out of 14 residents stated they have observed staff sleeping during the night shift hours. It is unknown if night shift staff are on break when they have been seen with their head down on the office counter. Based on interviews conducted, there is insufficient evidence to support the allegation. 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 . Exit interview conducted with Executive Director Jacqueline Cortez. A copy of the report was issued.