Inspector’s narrative
What the inspector wrote
Staffing for the month of Dec. 2025: 5- AM shifts with 2 caregivers/ 1 med tech; 5- days with 3 caregivers / 1 med tech AM; 21- days with 4 or> caregivers/ 1 med tech AM; 1- day with 3 caregivers / med tech PM; 30- days with 4 or> caregivers/ 1 med tech PM; 12- days with 2 caregivers ON; and 19 days with 3 or> caregivers ON.
Staff interviews found that staff who worked during Nov. and Dec. 2025 experienced a number of staff leaving and new staff being hired.
Staff stated that given the duties and acuity of residents in memory care such as 2 person assists, incontinent care, bathing, dressing, monitor wanderers, fall prevention plans, assist with eating , laundry, serving/ bus tables, cueing, transfer assists and unexpected occurrences, if there are too few staff, they were unable to provide care as outlined in individual plans. While staff responses varied regarding the ideal number of staff, they uniformly stated that 3 experienced staff on AM/PM made it likely that there could generally provide care as outlined in care plans with minimal occurrences of delays in care and that AM/PM shifts with only 2 caregivers made it impossible to attend to resident needs timely.
LPA reviewed incident reports submitted by the program and conducted records review of seven residents for whom there had been reported incidents. Summary of the review:
R1- dementia diagnosis, food restrictions, incontinence, wandering/ exit seeking, confusion and aggressive episodes. RO records found incident for 11/26/25.
R2- dementia diagnosis, incontinence, transfer assistance and ADL assistance.
Incident reported for 10/16/25.
R3- dementia diagnosis with extensive history of behavioral episodes, full assist with ADLs and incontinence care, required close observation for behaviors and inedible objects in their mouth. Incidents of falls, behavioral disturbances and sleeplessness on ONs.
R4- dementia diagnosis, vision impairment, incontinence, food preference. 8/30/25 incident.
R5- dementia diagnosis, food restrictions; incontinence assist, walker use/ wheelchair, confusion, "sundowning" and stand by assist for ADLs. Incident on 8/5/25 hospital care..
R6- Parkinson’s diagnosis with dementia, having CHF, hemiplegia and a catheter.
Incidents on 8/5/25, 9/6/25 and 9/6/25.
R7- Records found that R7, had a reported incident on 9/9/25 and has moved to assisted living before this investigation.
Interviews of staff and family regarding R1 found R1 to regularly wander within the memory care unit, trying to open doors and, at times, to enter other resident rooms. When resident care demands were high and staffing low, staff were not able to maintain awareness of R1’s status or location. R1’s service plan was for staff to “closely observe and guide wandering”. R1 would impulsively eat and had difficulty managing food. R1 was to be 1:1 staff assist while eating. R1 was twice hospitalized for aspirations, was observed by family, on one occasion following an aspiration hospitalization, with cheeks full of food. On one occasion, it was reported in interviews, R1 required another visitor to the facility to perform the Heimlich due to R1 choking (staff present at the time of the incident were not identified).
Interviews of staff and family regarding R6 found that R6 was known to be a fall risk and to have cognitive impairment that effected their ability to effectively use a call pendant and limited their awareness of their ambulation limitations. Family estimated R6 required cues/ reminders every 20-30 minutes in order to be more successful with their fall prevention plan. Staff interviews found that R6 quickly forgot safety information provided. R6’s assessment found a high level of care need. R1, according to staff interviews, would regularly be found on their floor without injury and R6 would be unable to explain how it occurred.
Interviews of staff and families also found R6 had a catheter and that catheter care of changing and flushing was done, in the community, by a family member who was not a licensed professional. This issue is addressed in an additional case management report.
While records and statements found a large variability in staff scheduled per AM/PM shifts, from 2 caregiver and a med tech to 4 (or more) caregivers and a med tech, the vast majority had at least 3 caregivers.
Staff statements that when there were 2 caregivers, for approximately 30 memory care residents, their main concern was safety. Resident ADL and incontinence care, schedules, monitoring could not be adhered to and posed potential risks to residents in care.
Title 22 requirements are that a resident with incontinence either have a
structured bowel and/or bladder retraining program to assist the resident in restoring a normal pattern of continence or a program of scheduled toileting at regular intervals. Incontinence garments may be used.
As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed with Administrator . Copy of this report and appeal rights provide.
Staff interviewed stated awareness of the monitoring and that in providing care, efforts were made to view the wound site. Staff also stated that R1’s behavioral expressions around bathing, dressing and incontinence care, coupled with family insistence on doing showers presented challenges to care and effective monitoring of the wound.
Staff insufficient care and supervision lead to residents choking on food incidents.- Interviews of staff and families found that there were incidents of residents choking on food or drink. However, LPA was unable to find a direct relationship between care and supervision and the occurrence of a particular incident.
Resident was assigned a fee increase though care identified was not provided- Health and Safety Code 1569.657 the licensee may increase residents’ care cost, following an reappraisal that identifies the increased care needed and provided. R5’s appraisals documented increased care needs that prompted a increase in fees. The licensee must then notify the resident and/or representative within two days of the increase.
Regulation requirements were followed and a meeting is available between the representative and facility staff to discuss the care and fees for R5.
As a result of this investigation, LPA finds allegation to be (US)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.
Exit interview with administrator and report copy provided.
