complaint·December 6, 2025

(continued from 9099) Allegations: Staff did not respond to resident's call button in a timely manner. It is alledged that resident pressed call pendant due to fall and staff did not respond in timely manner. - Staff left resident on the floor for an extended period of time. It is alleged that resident was on the floor for an unreasonable amount of time. On November 7 , 2025 at approximately 5:00am, R1 had a fall, hit head on the closet doors and fell to the ground. R1 stated R1 pushed call pendant, and R1 waited for what seemed to be a very long time. Several staff blamed other co-workers for the delay. LPA reviewed the call light log for November 7, 2025, and it showed that R1 pressed the pendant at 4:57:00 AM, at 5:06:11AM, the pendant pressed cleared, 9 minutes and 11 seconds after it was initially pressed. At 5:06:00AM, R2 pressed R2 pendant to get assistance for R1 who remained on the floor. At 5:18:42 it was acknowledged by: desk, front. At 5:30:17 AM, the pendant pressed cleared. Based on records reviewed, the resident spent 9 minutes 11 seconds on the floor or 24 minutes 17 seconds on the floor. Both times are unreasonable for any resident to spend on the floor. One staff member stated it was about 30 minutes that resident spent on the floor. R2 stated it was more like an hour. There is sufficient evidence to substantiate both allegations. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was provided. (continued from 9099A) The investigation revealed: Allegation Facility does not have adequate staffing to meet resident's needs. It is alleged that the facility does to have enough staff to meet resident’s needs. LPA interviewed seven (7) staff and five (5) of seven (7) staff denied the allegation. LPA interviewed eleven (11) residents and nine (9) of eleven (11) residents agreed that facility could use more staff. LPA reviewed the current schedule, and it shows the facility schedules three (3) to five (5) caregivers plus two (2) to four (4) Med-Techs during the day. The schedule shows the facility schedules two (2) caregivers, one (1) front desk and one Med-Tech during the NOC shift which is 10PM – 6:00AM. Facility appears to have sufficient staff scheduled to meet residents needs. There is not enough evidence to substantiate this 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. A copy of this report was provided to staff.