complaint·March 9, 2026

It was alleged that the facility does not have enough staff, when the elevator was temporarily down recently the facility did not have enough staff to help residents get up and down the stairs, and during a recent weekend there was only one medication technician and one caregiver on duty. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. Per the facility’s resident roster, the facility has 82 residents. LPA interviewed AD who stated the facility is always trying to improve staffing, and although there are callouts, the facility has always had enough staff to meet residents’ needs. LPA interviewed the facility’s wellness coordinator who stated that the staff schedule provides for one medication technician for each shift and three caregivers for the day shift, two or three caregivers for the afternoon shift, and two caregivers for the overnight shift. Per the facility’s wellness coordinator, two caregivers plus a medication technician is sufficient to meet the needs of the residents. LPA reviewed the facility’s staff schedule which generally shows there is one medication technician scheduled per shift, three caregivers scheduled for the day shifts, and two caregivers scheduled for the overnight shift. LPA reviewed the facility’s payroll records which shows that on Saturday, February 28, 2026, both caregivers that were scheduled for the afternoon shift of 2:30PM to 10:30PM called out, one of the three caregivers that were scheduled for the morning shift stayed late to cover until 6:30PM, and a backup staff was called to cover from 5:00PM until 10:30PM. Based on these payroll records, in addition to the medication technician, there was only one caregiver between 2:30PM and 5:00PM and again from 6:30PM to 10:30PM on Saturday, February 28, 2026, which is lower than the two care staff that would be sufficient to meet residents’ needs per the facility’s wellness coordinator and lower than the three care staff planned for by the staff schedule. LPA interviewed 10 residents and obtained corroborating information that staffing at the facility is sometimes short, particularly on weekend evenings, leading to staff being spread too thin and rushing care for residents and not providing enough individual attention. The resident interviews provided conflicting information regarding staff helping residents up and down the stairs during the period the elevator was down and did not provide information indicating that short staffing led to any injuries or incidents involving residents. The information obtained corroborated that the facility did not have sufficient staff to meet residents’ needs, but did not corroborate any immediate threat or harm to residents in this instance. 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.