complaint·February 23, 2026

One (1) out of eleven (11) residents interviewed stated staff would come timely to assist the resident when the staff was called. The staff would come to resident’s room in about 10 minutes after the call button was pressed. Nine (9) out of eleven (11) residents stated night shift staff did not come to assist them timely when staff were called. The interviews revealed that the night shift staff either did not show up in residents’ rooms to assist them or staff would come to assist them from 30 minutes to hours after they pressed the call pendants. It was a concern of short of staff at the night shift staff. Per staff interviews, one (1) out of four (4) staff interviewed could not corroborate the allegation. Three (3) out of four (4) staff interviewed corroborate the allegation which some staff failed to respond to the residents’ calls, especially during the night shift. During the facility tour, LPA tested the call pendants in seven (7) random residents’ rooms. LPA pressed the call button every five (5) minutes and waited in the residents’ rooms for 15 minutes to 25 minutes. Three (3) out of seven (7) residents’ rooms got no staff showed up. LPA spoke with staff to see if they received resident’s calls but staff stated they did not receive the calls. LPA and staff tried the call buttons multiple times to send the calls to front desk and finally, some calls were received by staff’s pagers. Based on the call button test, it showed some pendants were not working properly and staff failed to respond to resident’s calls in a timely manner. 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 with Administrator. A copy of this report and appeal rights were provided.