complaint·December 18, 2025

LPA inspected the facility in October 2021 and noted that there were not enough staff to readily assist LPA with the inspection, as all care staff were occupied providing care, the only office staff present had to cover reception until they were relieved, and the administrator at the time did not arrive until much later in the day. LPA also observed unpleasant odors from one memory care room, an unpleasant odor in the hallway possibly coming from one of the residents, and one memory care room had stains, crumbs, and debris on the floor as well as stains on the walls. When interviewed, the administrator at the time confirmed that the memory care recently had staffing issues, confirmed there was a lot of recent staff turnover, but otherwise denied the allegation, stating the facility was meeting its own staffing ratio with its staff and was also using a staffing agency to supplement staff. LPA reviewed the facility’s labor hour reports which indicate the number of caregiver hours were consistent from June through September 2021. LPA reviewed staffing agency invoices showing a small amount of staffing agency coverage during this time. LPA reviewed the facility’s termination report which shows that from June 2021 to the end of September 2021, 22 staff quit or were terminated. LPA interviewed five staff who corroborated that around September 2021, the facility had severe staffing issues due to staff turnover, there were fewer staff than there were supposed to be, especially in memory care, which negatively affected resident care, increased wait times for care, and increased the workload which caused more staff to leave. Staff interviewed also confirmed that there were instances where there was only one caregiver in memory care, that memory care would pull staff from the assisted living section leaving that section understaffed, and that the overnight shift was unable to meet the needs of the residents and left them all wet in the morning without changes. LPA interviewed six residents, five of whom corroborated that the facility had lost a lot of staff recently and three of whom confirmed residents were impacted by the staffing issues, including with longer wait times. Regardless of whether the facility was meeting its own staffing ratio, interviews with multiple residents and staff confirmed that the facility’s staffing level was insufficient to meet residents’ needs, including incontinence care. 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. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.