complaint·February 11, 2026

9099C-1.. Resident (R1) stated on December 27, 2023, that they are incontinent and wear diapers/pads. and has had issues with caregiver (S1) regarding not always receiving assistance with their bowel movements, since on/around October 2023. (R1) indicated that (S1) does not do their job because they were informed by another caregiver staff on the "pm" shift that they have to always change resident's diapers right after the shift change. A second resident was attempted to be interviewed on December 27, 2023 but was not able to participate. Staff (S1) stated on December 27, 2023 that they check on each resident every (2) to (2.5) hours, will receive alerts from residents needing assistance, and will chart all care provided to residents. (S1) stated that they assist with toileting/diaper changes within a reasonable time frame as long as they are not working with another resident and commented that they are responsible for (22) rooms on the first floor today. On December 27, 2023, the Wellness Director stated (S1) has received employee write-ups and confirmed she has spoken to (S1) several times about why their "daily sheet stack" is insufficient compared to (2) other caregivers. Documentation related to care provided to (R1) was not available for review, and LPA was not able to conduct a follow up interview as (R1) moved out prior to passing in early December 2025. On February 11, 2026, the administrator confirmed with the LPA that (S1) is still presently employed at the facility, "has been doing good on light duty" and is not doing care currently. Based on information gathered, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099C-2.. 9099C-2.. Allegation: Staff does not respond to resident calls for assistance in a timely manner. The allegation states that when (R1) requests staff assistance from (S1), (S1) does not come and check on (R1) and will claim they did not see the call light on. (R1) was interviewed on December 27, 2023 and stated they could not provide time/date of the incident but was told numerous times by (S1) that they would come back to check on (R1) needing to return to the toilet in 45 minutes to an hour, but (S1) would never come back and would not respond to the pendant either when (R1) pushed it. (S1) stated on December 27, 2023 that in September or October, 2023, the pendant/call button may have not been working due to the Wi-Fi server. (S1) confirmed that staff receive resident pendant alerts through their phone, and the alert includes the name/room number of the resident. When heard,staff will go to room to clear the alert with the magnet held onto by the caregiver, and confirmed staff will respond within (15) minutes, which is the facility protocol, but (S1) responds in approximately (10) minutes each time. (S1) stated that there was one time, around the end of August or early September 2023, when (R1) was calling for assistance, but (S1) was with a resident whose doctor was cleaning their bed sore. (S1) stated that while with the doctor and resident, the front desk lady called on the walkie-talkie to alert them that another resident needed help. (S1) explained that (R1) had already been helped when they went to attend to them, explaining they did not recall what (R1) needed, but was sure they were not neglecting (R1). The administrator stated on December 27, 2023, that all residents have a pendant and a call button in the bathroom, caregivers have their own cell phones that are primarily utilized as an alert system, and caregivers are required to respond to resident calls within a 7-15 minute time frame. On December 27, 2023, the LPA had requested the call light history for (6) residents starting from July 2023 through the request date; however, this documentation was not available for review when drafting the complaint findings. Based on information gathered, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099C-3.. 9099C-3. An additional complaint allegation was received by the Department on February 21, 2024. The allegation states it took the facility (3) months to fix the broken air conditioner in (R1's) apartment. ((R1) was provided with a temporary air conditioning while the unit was being repaired/replaced, but (R1) did not like the temporary unit. The allegation states the administrator did not return calls to (R1's) family regarding the temporary air conditioning unit during this (3) month time period. The Department requested and was promptly provided with documentation related to the repair and replacement of the Air Conditioner (A/C) unit in (R1's) apartment. On February 2, 2026, LPA was provided with a copy of an invoice showing the A/C unit had been replaced on/around January 10, 2024. On February 3, 2026, LPA was provided with a repair estimate invoice for a gas leak check for the "whole system unit" in (R1's) apartment. Additionally, LPA reviewed an email sent by the facility Maintenance Director, on October 16, 2023, for approval to make the repair. In the email, the Director notes that the request is "urgent" as there is a resident currently living in (R1's) apartment. The request was promptly approved on October 17, 2023 (9:22 am). On February 11, 2026, LPA contacted Administrator, Carmen Galicia, who indicated she started working at the facility around the end of September, 2023. The administrator stated that (R1) already had a portable, temporary A/C unit in their apartment at this time, and she was not made aware any issues related to the temporary A/C unit until October 2023, when the Health and Wellness Director, informed her. The administrator stated that since the parts arrived late, the A/C unit was only partially fixed, as they couldn't complete the repair. The entire unit was replaced in January, 2024. Additionally, there was the delay of (R1) refusing to temporarily move to another apartment for 2+ days while the new unit was being installed. (R1) finally agreed to move to another unit due to dust coming through the window from the gardeners outside. The administrator stated that (R1's) family reached out to her by email and she responded back timely. Based on information gathered, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report was emailed to the Administrator, who agreed to sign/return by email by 2/11/2026.