complaint·December 29, 2023

Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to deliver findings for the allegations noted above. LPA met with Jina Borja, Health and Wellness Director, and explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews, and records review. On 08/28/2023, Community Care Licensing received an allegation that staff left residents unsupervised during a fire alarm incident. On Friday, 08/25/2023 at approximately, 7:40 pm, a fire alarm was set off in the Assisted Living area by a resident in Memory care located adjacent within in proximity. During the incident, it was reported residents came out of their rooms and looked for staff for assistance, but no staff was around. Of the interviews conducted with residents, the general consensus from residents indicate staff were on the premises. Residents were instructed to returned to their rooms until the fire alarm was disconnected. Of the interviews conducted with staff, along with a review of staff work schedules and time sheets, there were nine staff on duty who were present and available to help all residents during the incident. LPA was also informed by General Manager, Billy Tames that managers were immediately notified by lead staff on duty, and management arrived at the facility within minutes to further assist as managers are on-call for emergencies. Based on observation, interviews, and record review, the allegation that staff left residents unsupervised is UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided to Jina Borja , Health and Wellness Director.