Complaint·March 6, 2025

LPA Moleski reviewed staffing schedules for assisted living and observed that at least two caregivers were regularly scheduled for each cottage during morning and afternoon shifts, with one medication technician scheduled per shift to cover the two assisted living cottages. One caregiver was always scheduled for each cottage for each night shift. LPA Moleski reviewed staffing schedules for memory care and observed that two caregivers were regularly scheduled to work in each cottage for morning and afternoon shifts. On some days out of the week, one medication technician/caregiver was scheduled to work in Dogwood cottage, who also covered medication technician duties for Elm and Fir cottages. On other days out of the week, there was a dedicated medication technician/caregiver scheduled for Dogwood cottage, and another medication technician who floated between Elm and Fir cottages. Title 22 of the California Code of Regulations does not provide specific staff-to-client ratios which must be maintained at all times. 22 CCR § 87411(a) states that “facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.” 22 CCR § 87415(a)(2) states that “in facilities caring for sixteen to one hundred residents at least one employee shall be on duty on the premises, and awake,” and that “another employee shall be on call, and capable of responding within ten minutes.” There were 58 residents being cared for at this facility at the time LPA Moleski opened this complaint investigation on 11/21/24. During a tour of this facility on that date which included a survey of Aspen, Birch, Dogwood, Elm, and Fir cottages, LPA Moleski observed a minimum of two staff members present in each cottage, and did not observe any residents with any obvious signs of unmet needs, such as poor hygiene, or unmanaged pain, et cetera. Resident rooms inspected during this visit were clean and free of odor. LPA Moleski reviewed six residents’ files (R8-R13) for potential signs of neglect due to lack of care and/or supervision, such as an unusually large number of documented falls, evidence of open wounds, missed doses of medication, et cetera. LPA Moleski observed no concerning trends in any of these resident records. LPA Moleski interviewed seven residents (R1-R7). R1, R2, R4, R6, and R7 voiced no concerns with the current level of staffing in the facility. R2 described the facility as “really good,” and said caregivers respond to them quickly. R6 said that the facility has an abundance of staff who are kind and helpful. R3 said that the facility’s caregivers “need more help.” R3 said that staff take too long to respond to their calls for assistance, sometimes up to 30 minutes. R5 said the facility was “understaffed.” R5 said that they sometimes have to wait four or five hours to be repositioned in bed, and they sometimes wait up to 40 minutes for a response to their calls for assistance. [continued on 9099-C] LPA Moleski reviewed 30-day call button response logs for R3 and R5. While the average response time for each resident was roughly in line with the facility's expectation of 15 minutes per call at 14:13 and 15:11 respectively, there were a number of unusually high response times. For example, R3 had a recorded response time of more than 128 minutes on 2/23/25 and more than 80 minutes on 2/10/25. R5 had recorded response times of more than 77 minutes on 2/24/25, more than 57 minutes on 2/23/25, More than 65 minutes on 2/16/25, more than 80 minutes on 2/11/25, more than 181 minutes on 2/10/25, and a second call for more than 99 minutes on that same date. The facility’s health services director (S2) said that these entries showing excessive response times were likely errors. S2 said that the facility was in the process of changing call response systems due to these persistent errors. LPA Moleski noticed that a number of R5’s calls were recorded as coming from Birch Cottage, including the excessively lengthy calls from 2/24/25 and 2/10/25. However, R5 lives in Aspen cottage. R3's call log, meanwhile, included an entry from Dogwood cottage — the excessively long call recorded 2/23/25 — and a few calls had no location indicated. R3 also lives in Aspen cottage. To demonstrate the errors occurring in the electronic record-keeping system, S2 provided call button response logs from Fir and Elm cottages, which are not equipped with call buttons. These logs show a number of extremely long and extremely short response times recorded for the month of February 2023, ranging from a few seconds to several hours. LPA Moleski interviewed 15 staff members of this facility. Interviews with staff corroborated the staff schedules previously reviewed by LPA Moleski. The majority of caregivers, medication technicians, and management staff indicated that there are at least two caregivers stationed in every cottage serving residents, and when caregivers are busy providing two-person assistance to any particular resident, then a floating medication technician will cover the cottage floor to supervise residents. The majority of caregivers indicated that the medication technician will also cover them while taking breaks or while they are otherwise indisposed. S7 said that they have had to work alone in their cottage, but also said that they have always been able to meet the residents’ care needs. S8 said that there have been instances where there was just one caregiver in their cottage, and said that even two caregivers are not enough. However, S8 also said that all care tasks are completed, and residents do not have unmet needs. S9 said the current staffing levels were “challenging,” but also said that they are able to take care of all the residents. S9 said that the memory care director has asked staff to stay late to ensure sufficient coverage was maintained. All other staff members interviewed did not voice significant concerns regarding staffing levels at the facility. [continued on 9099-C] The department has determined the following as it relates to the allegation that the facility has insufficient staffing to meet resident needs: Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Dial.