complaint·January 10, 2024

[CONTINUED FROM LIC 9099] Per interviews of facility managers: The facility is divided into an Assisted Living (AL) section and a Memory Care (MC) section. The MC section is further subdivided into separate “J Court” and “M Court" buildings. The PM caregiver shift ends at 11:00 PM, and the overnight (NOC) caregiver shift starts at 11:00 PM. Around the time-frame of the allegation, there were 115 total residents in care. Based on those residents’ care acuity levels at that time: PM shift was considered safely staffed if there were at least four (4) caregivers in AL and at least four (4) caregivers in MC. NOC shift was considered safely staffed if there were at least three (3) caregivers in AL and at least three (3) caregivers in MC. NOC shift was also expected to have one (1) med aide on duty to share between AL and MC; this person was cross trained and able to cover caregiving duties, if needed. Outgoing staff were expected to verbally debrief their incoming counterparts (of shift happenings) in one-to-one conversation. According to caregiver work schedules: on the night in question, there were four (4) PM caregivers assigned to AL and four (4) PM caregivers assigned to MC. There were two (2) NOC caregivers assigned to AL and four (4) NOC caregivers in MC. Per these work schedules, Licensee had planned on meeting its caregiver staffing targets for PM and NOC shifts, at least at the net (facility-wide) level. However, employee timeclock records showed that there were a few staff whose actual timeclock entries deviated from their assigned work schedule, such that the facility was short-handed in specific sectors at specific times, which had a potential impact on resident health and safety. According to electronic timeclock records, which were read in concert with the caregiver work schedules: On the night in question, within the MC “J Court” Building, PM Caregiver Staff #1 (S1) clocked out at 10:56 PM and PM Caregiver Staff #2 (S2) clocked out at 10:57 PM. The early departure of S1 and S2 was not counteracted by either of their two “J Court” NOC relief caregivers starting work early [i.e., NOC Caregiver Staff #3 (S3) clocked in at 11:00 PM, and NOC Caregiver Staff #4 (S4) clocked in late at 11:05 PM.] Although there was one NOC Med Aide Staff #5 (S5) who was on duty at the time and able to cover caregiving tasks in AL, the result was that MC “J Court” was still short-handed by one staff during a brief time-period that was relevant to the complaint allegation. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] On the night in question, within the AL Building: NOC Caregiver Staff #6 (S6) was 44 minutes late to work (i.e. clocked in at 11:44 PM). There was just one other NOC caregiver teammate, Staff #7 (S7), assigned to the AL building, instead of the usual two. While some PM staff lingered on duty beyond the end of their shift, the last PM staff person clocked out at 11:22 PM, rather than remaining on duty until S6 arrived. For the next 22 minutes, AL section was short-handed by at least one staff during a brief time-period relevant to the complaint allegation. Based on interviews and records, a preponderance of evidence exists to show that for a portion of the night in question, Licensee did not employ staff sufficient in numbers to meet a resident's care needs. The allegation is therefore substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Armour, to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.