complaint·October 29, 2025

9099C-1... One staff stated there are less than (10) residents that need toileting help and they have not seen any issues, and commented that the facility is "understaffed on the weekends, especially on the "pm" shift which has less people". This staff added that the "am" shift has the best caregivers" and they are more consistent; whereas on the "pm" shift, residents have to wait longer due to 1.5 staff only". Another staff confirmed that residents will call for toileting assistance sometimes in between their scheduled incontinent checks and feels all staff "do a great job" commenting "we all are pretty prompt" ; however, stated the "pm" shift is overwhelmed and overall the facility is short staffed. One resident (R1) stated to LPA on 10/24/25 (Friday) (3:30 pm) that they have not been provided with incontinent care since 8:00 am this morning when they woke up and a staff changed them. This resident confirmed they have pushed the pendant, but the facility is "short staffed on all shifts", asserting "they are supposed to change me (incontinent) four times per day" and provided LPA with the scheduled times and staff (S1) who always attends to them promptly, is off today, but usually brings them tomato juice in the morning. Staff schedules show (S1) works on the "am" shift, from Sunday through Thursday. (R1) stated to LPA that no staff had come to check on them, including bringing water, since 8:00 am this morning, pointing to their bedside table. Within (5) minutes of LPA speaking to (R1), LPA observed (3) staff knock and enter the room to offer incontinent assistance and empty the trash. Another resident (R2) stated t hey were not helped in the restrooms timely and complained a week ago Thursday, Oct 16, 2025, that there were "no caregivers on staff from 2:00 pm- 6:00 pm". This resident stated they "had an emergency" on the toilet and explained how they called the front desk and "no one answered" , until they told the Resident Services Director (RSD) and the Administrator, who brought them more toilet paper they were asking for. This resident also stated "no one answered the pendant" when they pushed it and added there are less staff on the "pm" shift, and staff are less trained" than the "am" shift. Based on information obtained, LPA finds this allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. *cont on 9099C-2.. 9099C-2. Allegation: Staff are not providing adequate food service to residents. The allegation states many residents complain about the food they are served due to it being not hot enough and being served at a lukewarm/room temperature. On July 24, 2025, LPA interviewed the administrator and Resident Services Director (RSD) about the food service. The administrator stated there is currently an opening for "Chef" in the Culinary Dept and one of the cooks stepped up temporarily to cover. Additionally, the administrator stated menu selections are updated on a weekly basis, and plates were previously sitting on the warmer and for an unspecified amount of time. The administrator explained the food service improved the beginning of July 2025- and they are "not plating the foot until the kitchen gets the order", and that there are "two daily specials- prepared in large quantities and kept on the steam table, and there is a daily Pre-Stand up meeting in the kitchen at 11:15 am. The RSD stated she is "not sure about the food temperature" and there was a "major change made in the beginning of July"- the change was so major that it's "more like a restaurant now - the food is not sitting on a warmer and was pre-plated before", and the improvement has to do with restructuring the way meals are ordered". LPA observed culinary staff, (S2), acting as the temporary lead chef, and (S3) present as a Prep Cook. (S2) explained to LPA how the "proofer" is used to warm resident plates to a temperature of 140*F before plating and serving the food. LPA observed (S2) to be preparing and plating food according to individual paper "tickets" displayed, and (S2) explained that culinary staff is "serving when the food is ordered, like a restaurant". (S2) indicated they have received "good feedback" on the new process and confirmed the shelf is hot- measuring 146*F. Also, on July 24,2025, LPA spoke with a few residents who were seated and eating lunch. One resident indicated the soup is "always hot" and that staff is "really kind" to residents and staff. A second resident stated she was served pizza and waffles the other day and it was "cold". On October 24, 2025, LPA interviewed multiple residents in the Assisted Living dining room during the lunch hour. Several residents stated the food temperature has improved over the last two weeks and the plates are now being warmed, which allows residents more time in eating their meal. A few residents stated they really like the breakfast choices but there are no low salt, diabetic options on the menu. *cont on 9099C-3.. 9099A-C-1. On 7/24/25, LPA requested resident pendant call response log was requested for the prior (30) days and was provided with (2) pages of a report entitled “Ave Response by Device by Category”. The report shows residents’ calls for assistance were responded to as quickly as (5) seconds and as late as (26) minutes and does not indicate what time of day/shift the resident calls were made. The administrator stated the (26) minute response was for a resident in Independent Living. The Resident Services Director stated staffing is scheduled as follows: AM: (3) caregivers and (2) Med-Techs (also help the caregivers); PM: (2.5-3) caregivers and (2) Med-Techs; and NOC: (1-2) caregivers and (1) Med-Tech. The RSD stated there are (50) residents in Assisted Living and (10-12) residents have "zero care needs", and some residents call for staff to raise the blinds in their room. Staff interviews revealed that staff is fairly quick to respond to calls on the “am” shift ; however, staff is often short staffed on the “pm” shift and so staff does not respond as quickly. Staff also indicated that residents have complained about having to wait longer for staff to assist. Staff stated they "used to have more non-emergency calls, but it has gone down- currently 5% of the calls are considered "emergency" where a resident has fallen or needs toileting assistance. Managers and a Med-Tech indicated that managers they will assist caregivers, when needed and everyone is cross trained. A Med-Tech stated there is a monitor in the med room and staff can see when a resident is calling for assistance. Also Med-Techs have a walkie (buzzes) to call the caregiver , and there are (2) Med-Techs in the morning who can help caregivers with what is needed as well as the Resident Care Coordinator and manager on duty who assists. The Med-Tech stated there are a lot of "non-emergency" calls where residents call for assistance with the light and water. Emergency calls are if a resident falls and the caregiver will respond, inform the Med-Tech who will go to their room and access, and call 9-1-1 if the resident fell or there is an emergency. This staff indicated staff respond within (10) minutes average. A few residents stated they were told they are "not supposed to use the pendant unless it's an emergency", with one resident stating "staff is "busy doing showers". One resident stated staff will respond within (5) to (15) minutes. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED-meaning although the allegation might have happened or is valid, the preponderance of evidence standards hasn’t been met. *cont on 9099A-C-2.. 9099AC-2.. Allegation: Licensee did not ensure that a comfortable temperature for residents was maintained at all times. The allegation states the facility was out of electricity from 5 pm to the early morning hours the next day. It was very hot inside the facility, the residents were very uncomfortable, and it appeared the facility was not prepared for this outage. LPA observed the temperature to be noted as 72-73*F inside when present in the facility on 7/24/25 and 10/24/25. (3) residents interviewed recalled the outage incident but did not recall the interior temperature becoming uncomfortable. Residents stated the facility provided each resident with a whistle, a flashlight, and there was emergency lighting in the hallways during the outage, which lasted approximately (2) hours, from 9:00 pm - 11:00 pm. The administrator stated all managers were notified and acted promptly, and all (3) residents using oxygen were handled appropriately. The incident report to the department did not document any concerns with the temperature changing and becoming hot/uncomfortable for the residents. Additionally, LPA contacted the local fire department and there was not an incident report made at the facility during the outage. The RSD indicated the facility conducts regular emergency drills, as required. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED-meaning although the allegation might have happened or is valid, the preponderance of evidence standards hasn’t been met. '*cont on 9099A-C-3.. 9099A-C-3.. Allegation: Staff are not meeting residents' bathing needs. The allegation states residents are not getting showers on schedule due to a shortage of staff on shift The administrator stated on 7/24/25 that the facility is "kind of restructuring the shower schedules" and requiring staff to document if the ADL was completed or not",using an Android phone. Interviews concluded that residents who have a scheduled shower on the "pm" shift feel they have to wait longer since there is less staff. One resident stated they "never miss a shower because I am demanding" but feels other residents may be if they don't demand one. The resident explained their showers are scheduled twice/week, on Wednesdays and Sundays and "staffing is always bad on Sundays between 2 pm- 6 pm, but PM the staff who are scheduled are "very good - the problem is there is just not enough staff". A second resident stated they don't miss showers but may refuse if they don't feel well. One staff stated they are "not sure about the "pm" shift- could be standby shower assistance needed, but indicated there are more staff in the "am" due to more showers being scheduled in the morning. Staff interviews revealed that there is a a part time staff to assist with showers on both the "am" and "pm" shifts. On 10/29/25, the administrator stated that (2) additional care staff were hired for weekend "pm" shifts three weeks ago. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- meaning although the allegation might have happened or is valid, the preponderance of evidence standards hasn’t been met. Exit interview. Copy of report provided to the administrator. 9099C-4.. Several residents stated on October 24, 2025, the food temperature has improved over the last two weeks and the plates are now being warmed, which allows residents more time in eating their meal. A few residents stated they really like the breakfast choices but there are not low salt, diabetic options on the menu;however,the community does offer alternative options that change weekly. These options are for diabetics or anyone needing dietary accommodations. There were other concerns voiced by residents during interviews. One resident stated that they are "understaffed in the dining room with servers and with caregivers". This resident confirmed breakfast starts at 7:30 am and coffee is served starting then, off the cart, and believes there is "more training needed with the culinary staff as residents have to tell them a lot of details". A second resident stated the "ingredients are okay-there is a failure in assembling" the sandwich and gave the example that staff serve the mayo on the side instead of on the sandwich, which wasn't per their instructions. This resident stated breakfast is good, but the breakfast menu needs work as there is a "breakdown between the menu writer and the person who prepares the menu”. This resident stated, “staff need more training - newer people are less experienced”. Additionally, food is being served later with a longer wait time due to a "delay in following the menu", which could be an experience issue”. Multiple staff interviews indicated that they have heard residents complaining about the food being "cold a lot", a new lead Chef was recently hired, and many residents "don't have patience". Staff indicated there are "two servers currently and they need more servers" and explained that the other day, two residents got up and left after waiting 45 minutes for their food to be served. The administrator stated that the average service time is between 10-15 minutes for the entree and residents are starting with soup/salad. Meals are finished with desserts if desired. The administrator stated the steam tables stay on throughout the day and all food is tested for temperature prior to serving it. Also, food is ordered/delivered three days/week (M/W/F), so it shouldn't occur that the facility runs out of a particular food on a regular basis. Discussed personalized menu options. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 9099-D page. Exit interview with the administrator. Copy of report provided.