Complaint·August 23, 2025

Allegation: #1 : Facility does not have the ability to accommodate non-ambulatory residents with dementia in case of fire. The complaint alleges that there aren’t a lot of emergencies or fire exits for residents in care. From 11:00 AM to 1:00 PM, the License Program Analyst (LPA) interviewed the Resident Services Director (RSD), who denied the allegations. The RSD stated that the facility has multiple exit doors and sufficient staff to assist non-ambulatory residents. During the same period, the LPA also interviewed five staff members (S1-S5), all of whom denied the allegations. They mentioned that they have been trained to assist residents during a fire, particularly those with dementia. The staff further noted that both the dementia wings and assisted living wings have numerous emergency exits. And the facility has a number of staff working on any given day. Additionally, the LPA interviewed eight residents (R1-R8), all of whom denied the allegations and stated that they knew something about evacuating in case of a fire. Records of the facility’s Memory Care layout indicated that there are several fire exits throughout the building. During the facility tour on August 23, 2025, the LPA observed multiple fire exit doors, fire extinguishers, exit lights, and an Evacuation Plan poster with instructions posted in various locations. The LPA also noted that most fire exit doors open outward, facilitating safe exits from the building. Some doors open automatically when approached, eliminating the need for a push-button feature and allowing residents to navigate the facility safely. Report continued LIC9099-C Based on the information gathered, and the interviewed conducted, there is insufficient evidence to support the allegation. Although the allegations above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED . Allegation: #2 : Facility does not conduct emergency drills as required. The complaint alleges that the facility hasn’t been providing fire and safety drills, and that is creating a fire hazard for residents in care. On August 23, 2025, from approximately 11:00 AM to 1:00 PM, the LPA interviewed the Resident Services Director (RSD), who denied the allegations. The RSD stated that the facility conducts fire drills and fire safety training quarterly and provides in-service training for all staff. During the same time frame, the LPA also interviewed five staff members (S1-S5), all of whom denied the allegations and claimed they had been trained to conduct fire drills monthly. Additionally, they mentioned that they receive training in earthquake and disaster preparedness quarterly, and that the facility conducts annual fire drills for residents. The LPA interviewed eight residents (R1-R8) on the same day, all of whom denied the allegations. They stated they had attended some fire drills. The LPA reviewed records of the last in-service fire drills and disaster preparedness training, which were conducted on January 27, 2023, February 23, 2023, April 2, 2023, and July 31, 2025. The last Emergency Preparedness drill for residents took place on September 30, 2024. During a tour of the facility on August 23, 2025, the LPA observed multiple fire extinguishers mounted throughout the premises. Furthermore, on that day, the LPA noted that the facility experienced a power outage, and all staff were prepared to assist residents in their care. Based on the information gathered, and the interviewed conducted, there is insufficient evidence to support the allegation above. Although the allegations above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED . No deficiencies cited. An exit interview was conducted. A copy of this report was provided to the staff Giovanna Pazmino.