complaint·March 26, 2026

Allegation: Facility did not ensure that there is adequate staffing to meet the needs of the residents in care. It is alleged that during Fall 2025 there was not enough staffing in the Memory Care Unit, and as a result residents were not receiving dressing and grooming assistance, and were being transported to the dining room in pajamas. According to information obtained, the Memory Care Director was made aware of the aforementioned concerns, but took approximately 2 weeks to respond to emailed concerns and messages. Additionally, it was reported that the facility is alerted at least 1 hour prior to the resident being picked up for medical appointments, and when they arrive to pick up resident (R1), they are not ready and have soiled incontinence briefs. It is alleged that it has occurred between 10 AM - 11 AM. A total of 10 staff and 9 residents were interviewed. Staff interviews revealed that the Memory Care Unit has a census of 50, and is supposed to have 4 caregivers in the morning and afternoon shifts. During the night shift there should be 2 caregivers and 1 medication technician that cover the entire building, which includes the Assisted Living wings. Staff stated that in late October 2025, there were only 3 caregivers working both the day and evening shift, and the Memory Care Unit did not have in place a Task Sheet that states which residents require incontinence care. Staff said that at that time the Memory Care Unit had a census of 50, of which 37 residents required incontinence care, while the Assisted Living wings only had 16 residents that received incontinence assistance. The majority of the staff interviewed confirmed staffing shortages has made it difficult to meet the Memory Care Unit resident's needs, for example sometimes the night shift changes the resident's incontinence briefs at 2:00 AM or earlier, and they do not get changed until the morning shift staff start. NOTE: During the initial complaint visit (10/30/25), there were only three (3) caregivers working during the morning shift. Based on interviews and observations during today's visit, the physical plant condition of the Memory Care Unit and grooming of residents appears improved. However, the staffing shortages that were occurring last Fall 2025 affected resident care in the Memory Care Unit. There is sufficient information to support the allegation. Allegation: Facility is falsifying the staffing schedule. The complaint alleges that in October 2025, the staffing scheduled showed names of staff that were no longer working at the facility, and Administration staff did not remove staff names nor obtained staffing coverage for the Memory Care Unit. A total of 10 staff were interviewed. Staff said that in the month of October 2025, two (2) Memory Care Unit staff were placed on suspension, which resulted in a termination of employment. Additionally, a third Memory Care Unit staff was on leave, but their name still appeared on schedule. Staff stated the Memory Care Unit staff schedule was posted weekly, but was not accurate. Administration staff and the Memory Care Director denied the allegation, but acknowledged the posted staff schedule and documents provided to LPA do not reflect updated staffing changes and/or schedule because the terminated employee and suspended employee are still listed in the schedule, as well as the 3rd staff that was on leave. There is sufficient information to support the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Pursuant to Title 22 California Code of Regulations, the following deficiencies were cited (refer to LIC 9099D). Exit Interview was conducted, citations issued, appeal rights discussed, and a copy of the report was issued to Executive Director Maria Quizon.