Complaint·March 29, 2026

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility staff are not ensuring elevator is maintained in good repair It is alleged that the facility staff is not ensuring the elevator is maintained in good repair. There are concerns about the broken elevator at the facility, which has been out of service for 3 months and is affecting emergency evacuation. It is feared that, in an emergency, residents on the upper level may not be able to evacuate.  No further information is provided regarding this matter. On June 2, 2025, and March 28, 2026, between 09:15 AM and 03:10 PM, the Department interviewed resident members identified as Resident #1 through Resident #20 (R1-R20).  Ten (10) out of twenty (20) could not validate this claim.  Residents acknowledge that the rear elevator occasionally breaks down, but 10 residents could not support the claim that the elevators were down for 3 months and that facility staff did not ensure they were maintained in good repair.  (R2-R10 and R20) verified that the facility has a service contract with the elevator contractor and has observed them providing services to the elevators to maintain them in working condition, and that there was always one working elevator in service, and never encountered both elevators being out of service.  Residents will be informed that when elevators are out of service, their status and any delays will be communicated by facility staff. On June 02, 2025, and March 28, 2026, between 12:40 PM and 3:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #9 (S1-S9). Five (5) out of nine (9) staff members could not validate this claim.  (S1-S5) confirmed that the facility is committed to ensuring elevators are in good repair. (S1-S5) verified that there was always one elevator in working condition; they never had both elevators out of service. (S1 and S5) confirmed that the process for submitting work orders through the front desk is verified and that compliance documentation is up to date. The maintenance team reviews the work order summary daily, prioritizes tasks, and documents the time taken for each completed task. While most repairs are handled promptly, some may face delays due to the need for outside vendors or parts, as vendor-part orders delayed the rear elevator repair, which the facility had no control over.  (S5) highlighted that recognizing the facility's limited control over delays can help set realistic expectations and improve communication about repairs. (Evaluation Report continues LIC 9099-C) During the visits on January 31, 2026, March 5, 2026, and March 28, 2026, an inspection of the facility found both elevators in working condition and that the physical plant, including floors, windows, and doors, fixtures, and furniture, was in good repair. The Department observed that two evacuation chairs are available to transport residents with limited mobility downstairs during emergencies, when elevators cannot be used. A review of Amtech Elevator Services service contract invoices (dated 01/09/25, 01/13/25, 04/01/25, and 07/07/25) and email communications between Amtech and the administrator revealed that the facility was committed to ensuring elevators are in good working order. Upon further review of the Facility's Work Order Summary (dated 05/05/25 through 06/30/25), it was revealed that 70% of work orders are completed within 24 hours. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Allegation #2: Facility staff did not respond to resident's call button. It is alleged that the facility staff did not respond to Resident #1’s (R1) call button. It is reported that on May 27, 2025, (R1’s) call went unanswered after requesting a vital check from staff, who was not available, leading (R1) to seek assistance elsewhere. No further information is provided regarding this matter. On June 2, 2025, and March 28, 2026, between 09:15 AM and 03:10 PM, the Department interviewed resident members identified as Resident #1 through Resident #20 (R1-R20).  Fifteen (15) out of twenty (20) could not support this claim.  Residents have reported that response times for staff assistance via call buttons can vary. However, none of the wait times exceed 45 minutes, depending on the urgency of the situation and the time of day, according to (R2-R10, R14-R17, and R19-R20). Residents (R2-R10) expressed that they do not require their vital signs to be checked throughout the day, as their physicians specifically mandate this. Resident (R1) was interviewed on June 2, 2025, and March 28, 2025. On June 2, 2025, (R1) stated that the response time from staff after using the call button can be up to 2 hours. However, on March 28, 2025, (R1) reported that the response time could be as quick as 15 minutes and stated that there were no issues or concerns regarding assistance with vital signs. (Evaluation Report continues LIC 9099-C) On June 02, 2025, and March 28, 2026, between 12:40 PM and 3:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #9 (S1-S9). Nine (9) out of nine (9) staff members could not corroborate this claim.  All staff members respond at different times, but they do so as promptly as possible—no response within 2 hours of the call request is false. Staff members explained that the call buttons enable two-way communication, allowing them to ask residents whether a matter should be prioritized over other call requests. When a resident uses the call button in their room, it indicates a non-emergency situation. However, when the call button is used in the bathroom, it triggers an emergency call alert and sends a different signal tone to the front desk for immediate assistance. Caregivers and med-techs collaborate as a team in accordance with (S2). If a caregiver cannot respond quickly, the med-techs will step in to assist, or vice versa. On January 31, 2026, the Department conducted inspections of call buttons for residents in rooms #115, #118, #120, #132, #137, #143, #208, #226, and #252. The inspection found that all call buttons were functioning properly, with response times for assistance ranging from one to five minutes.  On March 28, 2026, the Department inspected room #254 for Resident #1 (R1) and tested both the room and bathroom call buttons. Both were found to be in working order, with response times under 3 minutes. A review of Resident #1's (R1) Medical Assessment for Residential Care Facilities for the Elderly, LIC 602A (dated 09/19/25), and the Department of Health Care Services In-service Plan (dated 09/18/25) revealed that primary physicians prescribe no mandated requirements for vital sign monitoring. Further review revealed that (R1's) medical diagnosis profoundly impacts (R1's) thought processes and belief system, intricately shaping (R1) perspective, understanding, and behavior. Further review of personnel training requirements revealed the facility is committed to training to improve the quality of care for residents. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Allegation #3: Facility staff did not dispense medications as prescribed. It is alleged that the facility staff did not dispense medications to residents. It is reported that medications were not dispensed correctly to another resident, with a med-technician taking away a pill after that resident refused it. It is reported that there are concerns about the qualifications of the med-technicians. No further information is provided regarding this matter. (Evaluation Report continues LIC 9099-C) On June 2, 2025, and March 28, 2026, between 09:15 AM and 03:10 PM, the Department interviewed resident members identified as Resident #1 through Resident #20 (R1-R20). Eighteen (18) of the twenty (20) residents reported no medication errors. Moreover, the overwhelming majority (18) of twenty (20) reported no awareness of any incidents involving the dispensing of incorrect medications and were complimentary of staff and their qualifications. The (2) residents who asserted knowledge of medication errors were unable to provide details such as the date, time, or names of the staff involved or residents and failed to notify management of the incident. On June 02, 2025, and March 28, 2026, between 12:40 PM and 3:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #9 (S1-S9). Nine (9) out of nine (9) staff members could not support this claim. (S1-S2 and S6) stated that facility staff have previously made medication errors in the past, which they are required to report to Community Care Licensing, the resident's physician, and the family representative using an incident report. However, (S1-S2) stated that no errors related to the specific complaint being discussed have ever occurred. According to (S1-S2), all med-technicians must complete mandatory initial training of 16 hours. This includes 8 hours of shadowing and 8 hours of instruction. Furthermore, they must pass a competency exam within the first two weeks of hire. To ensure ongoing, an additional 4–8 hours of annual refresher training is also required. An evaluation of Resident #1's (R1) Medication Administration Record from (dated 02/01/25 to 06/30/25), along with the records for Residents #2 to #7 (R2-R7) (dated 03/01/26 to 03/31/26), reveals that all entries are accurate with no errors or discrepancies. Further review of the mandatory training requirements revealed that the facility is committed to training not only to enhance skills but also to improve the quality of care for residents. The Department conducted inspections on March 5, 2026, and March 28, 2026, and observed that all resident medications were kept securely locked. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated . No deficiencies were cited An exit interview was conducted with Bobbie Rodriquez, and copies of the reports were provided.