complaint·August 19, 2025

LPA conducted (2) staff interviews which revealed there is (1) staff on call at night from 8pm to 6am and wait times for assistance are around (5) minutes. All staff interviewed revealed night staff is asleep at night, and all residents are able to verbalize their needs and call when assistance is needed in between checks. All staff interviewed revealed (2) residents require checks at night for incontinence care and turning every (2) hours. LPA conducted (6) resident interviews. All residents interviewed revealed there is (1) staff member at the facility on call at night from 8pm to 6am and residents need to call for assistance. (4) of (6) residents revealed staff come and check on residents and change and turn R1 and R2 at night with reported wait times of (3) to (10) minutes. (1) of (6) residents, stated staff responds fifty percent of the time at night, and reported waiting (30) minutes for assistance. (1) of (6) residents revealed they do not call for help at night. Therefore, based on pre-placement appraisal of night supervision needed for (2) residents, and the staff and resident statements that the only staff present is asleep and on call at night the allegation that the facility is insufficiently staffed to meet the needs of the residents is substantiated. It was alleged “Licensee does not have an appropriate emergency disaster plan”. It was alleged that there is not enough staff to assist residents in case of an emergency. LPA reviewed the Emergency and Disaster Plan LIC610E, listing the emergency agencies that will be contacted to assist with evacuation, and that staff from all shifts will be called to assist in evacuating and transporting residents. LPA conducted (2) staff interviews and (6) resident interviews revealing there is (1) staff present who is allowed to sleep from 8pm to 6am. All staff interviewed stated there is enough staff available to evacuate residents to safety with (1) staff on the premises and (3) staff on call in the vicinity to assist. LPA reviewed all resident LIC602 Physician's Reports revealing their ambulatory status and ability to transfer. (5) of (6) residents are non-ambulatory while (1) of (6) residents is bedridden. (6) resident interviews and (2) staff interviews revealed the bedridden resident requires total assistance when evacuating, (2) non ambulatory residents require assistance to get into and be pushed in their wheelchairs, while (3) non ambulatory residents have assistive devices they can access on their own and can evacuate on their own in case of an emergency. Therefore, based on resident ambulatory statuses and resident and staff interviews the allegation that the facility does not have an appropriate emergency and disaster plan is substantiated. Based on (1) staff being on call on the premises and (3) residents requiring assistance to evacuate in case of an emergency. The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report and appeal rights were reviewed and provided.