complaint·December 8, 2025

It was alleged that residents have to wait a long time to receive care when they activate their call buttons. LPA interviewed AD and WD who denied the allegation. Per WD, the expectation on staff is that calls for assistance are answered in 10 to 15 minutes, but during peak times such as meals many residents call at the same time to be taken to the dining room which increases response times. WD stated that if a new call comes in while a staff is already assisting a resident, the staff will go check on the new call to ensure it is not an emergency, go back to the resident they were assisting and complete the care they are providing, then address the new call. LPA interviewed 12 residents and obtained information that call button response times range from 15 to 40 minutes and received conflicting information about whether staff already assisting residents are pausing the care they are providing to check on new calls and determine if they are emergencies. LPA reviewed the facility’s call system logs and noted most calls for assistance are resolved within 15 minutes, but there were also multiple calls that took over 40 minutes, 50 minutes, and even an hour to resolve, which is too long for residents to wait for assistance with care needs or possible emergencies. AD stated that resident calls for assistance are first quickly answered by staff to determine the urgency and are only cleared once the care is completely provided. No information was obtained that the long wait times resulted in any injuries or illness to the residents. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that the facility is understaffed resulting in inadequate care and supervision for residents. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD and WD who denied the allegation, stating the facility has enough staff and is currently hiring even more staff. Per WD, the average staffing ratio is about seven or eight care staff for the whole building during the day shift and three or four care staff during the overnight shift. LPA reviewed the facility’s staff schedule which shows four or five care staff for the day shifts in assisted living, four or five care staff for the day shifts in memory care, and three or four care staff for the overnight shift for the whole building. LPA interviewed 12 residents and obtained conflicting information, with some residents stating that the facility has enough staff and other residents stating that the facility needs more staff to meet residents’ needs, especially the overnight shift. However, per WD and the facility’s staff schedule, staffing for the overnight shift has already been increased. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.