complaint·March 30, 2026

Regarding: Facility is short-staffed. It is alleged that the facility is often understaffed by having only two staff available to care for residents in the PM and NOC shifts on weekends. It is also alleged that diapering, bedside meal trays and wellness checks are delayed due to only two staff being on hand to provide care during a shift. Interviews with (6) out of (6) staff revealed that the facility is short-staffed. S1-S6 indicated that there are days in which only two caregivers are providing care for the residents in the PM shift because the facility is unable to get coverage for staff who call-out staff. S1-S6 further indicated that due to staffing shortages, specifically on weekend PM shifts, services like wellness checks, bathing and incontinent care are delayed. Interview with S1 indicated that the facility follows the Electronic Health Record (EHR) Acuity Based Staffing Estimates to maintain staffing balance when scheduling staff for work; however, it has been difficult to follow the staff balance ratio populated by EHR due to the high number of staff call-outs particularly for the PM shift which is 2:00-10:00 p.m. S1 further indicated that the facility should have (6) caregivers scheduled to work in the AM, (6) caregivers in the PM and (4) caregivers in the NOC shift, scheduled to work every day for the number of residents who live in the facility and the level of care the residents need from caregivers. Interviews with S1-S2 indicated that during short-staffed days, the two to three staff who report to work will have to “run it,” which means that caregivers must divide up the assignments for care of residents between the staff on shift and additionally, provide care for residents on their workloads. S1 and S2 indicated that call-outs are immediately addressed by calling other staff who are off shift to come in to cover; however, staff cannot come in to cover. Interviews with (10) out of (14) residents revealed that caregivers are late doing their wellness checks in the P.M. shift, two to three times a week, especially on the weekends. Residents indicated that they noticed that only two caregivers are on shift to provide care for the whole facility population and indicated that having only two staff is not enough to provide proper care for the residents who live in the facility. Eight (8) out of (14) residents indicated that caregivers are late in responding to calls from residents and have had to wait more than 20-30 minutes past the scheduled time for assistance with baths and incontinent care. Review of the current Electronic Health Record (EHR) Acuity Based Staffing Estimates indicated that the facility should have (6) caregivers scheduled to work in the AM, (6) caregivers in the PM and (4) caregivers in the NOC shift, scheduled to work every day for the number of residents who live in the facility the average census of the facility is 140-150 for the past two months. However, the facility did not follow the EHR plan and per interviews, the facility is not using a staffing agency. ***Continues on LIC 9099-C page 2*** Based on information obtained from staff and residents during interviews, and review of facility’s staffing model, the allegation that the facility is short-staffed is corroborated. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated . California Code of Regulations (Title 22), is cited on the attached LIC 9099-D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report and Appeal Rights were provided.