Complaint·July 31, 2025

Interviews with both 2 out of 2 facility staff revealed that the fire alarm in room #6 had been beeping since July 28, 2025, typically around 2:00 AM and 4:00 AM, and continued throughout the day. Staff confirmed that the alarm was removed by a resident in room #6 from the ceiling because of the nonstop beeping. Facility Designated Administrator (FDA) Tevita Kaloulasulasu acknowledged that staff informed him of the issue on the same day it began (07/28/2025). He stated that he visited the facility, observed the alarm, and heard it beeping, but had not yet resolved the problem. FDA Kaloulasulasu indicated that a maintenance worker is scheduled to come to the facility today to address the issue. Additionally, interviews with 4 out of 4 residents confirmed that the fire alarm beeps regularly throughout the day and that residents are not able to sleep because staff have not resolved the problem. This was found to be out of compliance with Title 22, Regulation 87468.1(a)(3) Personal Rights of Residents in All Facilities. The facility was not observed to be free from interference with residents' daily living functions, such as sleeping. Based on observations and statements gathered during the investigation, the LPA was able to corroborate the allegation. It was alleged that the facility does not have hot running water for showers. The investigation included observations and interviews with staff and residents. During today’s facility visit, LPA Lee, along with direct care staff Ratusione Nawavoli, tested the hot water in resident bathroom #1, located on the right side of the facility. The hot water was found to be functional and measured at 118.0°F. However, during interviews, 2 out of 2 facility staff admitted that the hot water had not been working prior to LPA Lee’s visit. Staff member S1 stated that approximately three weeks ago, the hot water in shower #1 (on the right side of the facility) was not functioning. Despite attempts to adjust the shower knob, only cold water was dispensed. As a result, S1 redirected residents to use shower #2, located on the left side of the facility, which is typically designated for staff use. S1 reported the issue to FDA Kaloulasulasu. In an interview with FDA Kaloulasulasu, it was confirmed that he had been informed of the problem by S1 but did not personally check the shower to verify whether it was working or dispensing hot water. This was found to be out of compliance with Title 22, Regulation 87303(e)(2) Maintenance and Operation. Facility faucets used by residents for personal care, such as showering, shall deliver hot water. Based on observations and statements gathered during the investigation, LPA was able to corroborate the allegation. Due to this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with direct care staff Ratusione and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.