complaint·April 3, 2025

It was alleged that on February 3, 2025, a resident called for assistance with using the restroom, had to wait an hour because there was only staff to assist all three floors of assisted living due to another staff calling out, and there have been multiple instances where wait times for assistance were up to 30 minutes. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA tested the call system in three separate resident rooms and observed that a caregiver responded each time in less than five minutes. LPA reviewed the facility’s staff schedule and noted that on February 3, 2025, there were two caregivers for the morning shift, three caregivers for the afternoon shift, and two caregivers for the overnight shift scheduled for all three floors of the assisted living section. Per the facility’s resident roster, the facility had 70 residents in assisted living on February 3, 2025. LPA interviewed COO, who denied that any staff called out on February 3, 2025. LPA reviewed the facility’s payroll records and confirmed that all staff scheduled to work on February 3, 2025, signed in to work that day. LPA interviewed two staff, one of whom admitted that on February 3, 2025, a caregiver was running an hour late so there was only one caregiver for all of assisted living, a resident called for assistance and was advised to wait because there is only one caregiver for assisted living, the caregiver went to the resident’s room and advised the resident they were the only caregiver and they had to assist other residents who had called first but that they would be back, and it is unknown how long the resident had to wait in total. LPA reviewed the facility’s call system logs which do not properly document this incident, as the response time indicated does not specify if it is for the time the phone call was answered, the caregiver was first sent to the resident’s room but did not provide the requested care, or the resident finally received care, meaning the facility does not have any documentation of how long the resident had to wait for care. LPA interviewed 12 residents, 11 of whom stated that response times are generally 10 minutes or less. However, one resident corroborated that wait times for care can be up to 45 minutes. LPA reviewed the facility’s call system logs which do corroborate that wait times can be up to an hour on occasion. The information obtained corroborated the allegation, as the facility was unable to provide timely care to a resident because of short staffing. 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. It was alleged that the facility’s call system was not functioning. LPA reviewed a facility incident report dated February 6, 2025, which states that on February 2, 2025 at 11:00AM, it was discovered that some of the call buttons had stopped working, troubleshooting of the system began, in the meantime regular checks were conducted on residents and residents were provided with the receptionist’s phone number as an alternative to the call system, troubleshooting of the system was completed on February 4, 2025 and new parts for the call system were ordered, and the call system was fixed a little over three days later on February 5, 2025 at 8PM. LPA interviewed COO and one staff who corroborated the information in the incident report and stated that the issue with the call system did not affect memory care and only affected the second-floor assisted living section. LPA reviewed a call system parts invoice dated February 4, 2025, which shows that the parts to fix the call system were ordered after the troubleshooting was completed. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA tested the call system in three rooms and observed the call system to be working properly. LPA interviewed COO and one staff who stated that after the issue with the call system was discovered, regular checks were conducted on residents, a notice was posted informing residents of the situation, residents were advised of the situation in-person and were provided with the receptionist’s phone number to call for assistance, and these measures mitigated the effect of the call system being non-functional for a few days. LPA reviewed a facility notice regarding the call system which states that the call system is out of order and advises residents to call the receptionist for assistance. LPA reviewed facility phone number cards showing the receptionist’s phone number which facility staff stated they handed out to all affected residents. LPA interviewed 12 residents and did not obtain any information that the call system being down affected their ability to call for assistance. LPA also noted that all residents interviewed had phones they are able to use and that many residents use their phones to call for assistance generally instead of using the call system. The information showed that although a portion of the call system did not function for a few days, the facility quickly repaired the call system and created an alternative system which mitigated any effects of the outage. 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.