complaint·April 23, 2026

Allegation: Staff are not trained to provide medications to residents. It is alleged that a staff administered a medication without training. It is also alleged that it was not charted in the Medical Administration Record and was recorded written on a separate medication chart. Based on record review, R1’s Controlled Drug Administration Record had S1 sign off on August 16, 2025, at 1:32 AM. R1’s Medication Administration Record only has a record of another staff administering the medication on August 16, 2025, at 9:08 PM. While reviewing S1’s training, the staff did not have training to administer medication to residents. Based on interviews conducted four out of five staff confirmed the allegation. One staff out of the five staff could not confirm or deny the allegation. Four out of five staff stated, S1 assisted R1 with their prescribed medication which was self administered. Based on information gathered through interview and record review, the preponderance of evidence standard has been met, therefore, the allegation Staff are not trained to provide medications to residents was found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6 Chapter 8. An exit interview was conducted, and a copy of this report including LIC811, and the appeal rights were provided to Adminstrator Austin Morris. Allegation: Staff does not respond to call button in a timely manner. It is alleged the time between the residents' pendants are pushed and when a caregiver can respond can be up to 20 minutes. Based on record review, the facility policy Resident Alert Call System states that the facility is equipped all residents with an alert call system. Staff will respond to all activation of the resident call system. It also states when a resident alert call system is activated, a caregiver will respond. There is no indication of a time frame of how fast the staff needs to respond to a call button being pressed. Based on interviews conducted, seven out of eight staff and nine out of nine residents denied the allegation. One out of eight staff confirmed the allegation. All residents stated that the staff responded in a timely manner when their call button was pressed. They also stated there was not a time they waited more than twenty minutes to receive assistance after pressing the call button. Seven out of eight staff stated that the staff responds within fifteen minutes to when a call button is pressed. Based on observations, on September 17, 2025, LPA observed two resident rooms where staff responded to call button being pressed within five minutes. On April 23, 2026, LPA observed five resident rooms where staff responded to the call button being pressed between 32 seconds to 19 minutes. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff do not ensure resident's care plan is updated. It is alleged new residents are not updated to shower schedule and level of care changes addressed correctly, for weeks. Based on record review, four residents out of nine residents have a shower schedule posted on their bathroom door. Based on resident appraisals, the facility keeps an update of all resident care plan needs. Based on interviews conducted, seven out of eight staff and nine out of nine residents denied the allegation. All residents who needed assistance for showers stated they have received showers on a regular basis and have not miss any showers. All residents stated prior to coming into the facility they recall having a care plan being done. They all stated that the facility regularly checks in on them and checks on their level of care and if there needs and services need to be updated. Seven out of eight staff stated that they regularly check with each other through crossover and through charting notes of any resident changes. Continued on LIC9099C Based on information gathered, there is not sufficient evidence to corroborate the above allegation Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegations Staff does not respond to call button in a timely manner and Staff do not ensure resident's care plan is updated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted a copy of the report was provided to Administrator Austin Morris.