Follow-up on corrections·October 28, 2025

On today's date, Licensing Program Analyst (LPA) Michael Tea conducted this case management in conjunction with the continued Complaint visit Control #: 22-AS-20251003170854. LPA Tea met with Executive Director (ED) John Goodwin and discussed the purpose of today's case management visit. During the course of the complaint investigation, LPA Tea verified through interviews that seven out of nine interviewees reported the facility was inadequately staffed at the time of the incident. Several staff members stated they were responsible for an excessive number of residents, with some indicating they were assigned to an entire floor independently. It was further reported that during the nocturnal shift in the Memory Care unit, only one care staff member was on duty. Insufficient staffing levels were described as negatively affecting the quality of care, timeliness of assistance, and overall supervision provided to residents. The LPA’s own observations during the investigation supported these accounts, indicating that the number of staff present was insufficient to meet residents’ needs. However, it was also noted that following the incident, the facility increased staffing levels across various shifts to provide more consistent coverage throughout the day. Based on documents obtained and interviews conducted, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director John Goodwin and Health & Wellness Director (HWD) Suzette Paige and a copy of this report LIC809 and LIC809D and appeal rights were provided at exit.