complaint·December 18, 2025

Continued from LIC9099A Review of facility schedule for 08/23/2025 showed that there were 8 direct care staff on-site during the evening shift. Review of staff records indicated that 8 of 8 facility staff members had first aid training certificates on file. This allegation is Unsubstantiated . The Department investigated the following allegation, “staff do not ensure that facility is in good repair.” Complaint alleged that facility’s camera system was not working. Complaint alleged that facility staff were aware that the system was down on the morning of 08/23/2025 but did not communicate it to residents or their responsible parties. Facility partners with a third-party vendor, Safely You, that has cameras throughout the building to notify the facility staff of a potential fall. Interview conducted with Executive Director stated that Safely You Technicians were on-site for 3 to 4 days to resolve the camera issue. Facility documents also indicated that on 08/29/2025, the Safely You cameras were online and active. The camera system is maintained and managed by Safely You. Therefore, it is the third-party vendor’s responsibility to ensure that their system is functioning appropriately and not the facility’s. This allegation is Unsubstantiated . A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 Review of R1’s call pendant records for August 2025 indicated that on 08/24/2025, R1’s pendant was pulled at 8:11AM and was not received or responded to as of 8:56AM. Review of R1’s call pendant records for September 2025 indicated that on 09/24/2025, R1’s pendant was pulled at 9:45AM and was not received or responded to as of 10:30AM. Additional review of R1's pendant call records also showed that on 09/25/2025, R1’s pendant was pulled at 6:06PM and was not received or responded to as of 6:51PM. Per interview with Health and Wellness Director, it was identified that some facility staff were not wearing or using their pagers as required. Health and Wellness Director also stated that they identified that the facility also had a low supply of employee pagers. Review of facility documents showed that an Standard Operating Procedure (SOP) document titled, "Use of Pagers for Responding to Pull Cord Alerts," was signed by facility staff on 08/30/2025. Based on record review, interviews, and observations made, this allegation is Substantiated . A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.