complaint·October 17, 2025

Additionally, ED added staff are now required to conduct resident checks every 10 to 15 minutes throughout the night. Information obtained from interviews with residents stated there were many incidents that required immediate attention and did not receive a response from staff in a timely manner. Further information obtained stated there was an incident where Resident #1 (R1) fell and required staff assistance. The information provided was corroborated by Witness 1 (W1), who stated they activated R1’s call pendant and verbally called out for help. W1 further noted that when staff eventually arrived, they explained the delay was due to assisting another resident with an emergency. Additional information obtained stated there was an incident where a physical altercation occurred between two residents. Staff was requested, but no staff responded. As a result, residents contacted law enforcement for assistance. Additionally, there were two documented incidents in which medications were not administered due to inadequate staffing. On February 1, 2025, the Night Operations Shift (NOC) lacked an assigned MedTech, resulting in at least two residents missing their scheduled medications, including any Pro Re Nata (PRN) requests. A second occurrence took place on Saturday, April 26, 2025, when an unexpected staff call-out prior to the evening shift, which left the facility without MedTech coverage. As a result, scheduled medications were not dispensed to residents. Interviews with the Executive Director and staff confirmed that attempts were made to secure coverage; however, due to emergencies, existing staff commitments, and the short notice, a qualified replacement could not be arranged for that shift. A review of the facility’s staffing schedule from January through May 2025, there are three shifts. During this period, the AM and PM shifts consistently maintained six to seven staff members who actively provide resident care, excluding office and kitchen personnel. In contrast, the NOC (overnight) shift, operating from10:00 PM to 6:00 AM, was inconsistently staffed with only three to four caregivers. The NOC shift was responsible for approximately 54 residents. The shortage in staff, compromised both the safety and the level of supervision provided to residents in care. This poses as a potential health & safety risk to residents in care. Based on interviews and record reviews, the allegation that facility does not have adequate staffing to meet resident's care needs. is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided to Executive Director Valeria Garcia, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.