complaint·October 24, 2025

Review of R1’s medical assessment date May 22, 2025, revealed that R1 is non-ambulatory and can feed themself but required assistance with all other Activities of Daily Living (ADLs). Interviews revealed that R1 requires a Hoyer lift to be transferred to their wheelchair from their bed. Interviews also revealed that the Hoyer lift requires two (2) staff members, and there have been instances where there is only one (1) staff member on-site at the facility. Due to only one (1) staff member being present at the facility, R1 could not be transferred until another staff member had to be called to come to the facility and assist with the transfer. During LPA’s initial visit on October 14, 2025, from 9:20AM-11:15AM, LPA reviewed facility records. Review of the residents’ MARs revealed that a staff member had initiated an administration at 12:00PM prior to it being 12:00PM. Review of R1’s repositioning checklist also revealed that a staff member had initialed the repositioning of R1 at 12:00PM and at 2:00PM prior to those times. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of evidence exists to support the allegations. Two deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Operations Manager Jessica Paz, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. Review of R1’s medical assessment date May 22, 2025, revealed that R1 is non-ambulatory and can feed themself but required assistance with all other Activities of Daily Living (ADLs). Interviews revealed that R1 requires a Hoyer lift to be transferred to their wheelchair from their bed and the Hoyer lift requires two (2) staff members to operate it. Interviews did not reveal that staff have transferred R1 with only one (1) staff member nor have staff operated the Hoyer lift if they are the only staff on site at the facility. Review of staff training records did not reveal that staff are untrained in medications. Records reviewed revealed that current medication trainings were maintained on file for staff members. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not meet resident’s transfer needs and staff did not have medication training. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Operations Manager Jessica Paz, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.