complaint·January 29, 2026

(Continued from LIC9099, Page 1) Interviews with staff revealed that staff are aware of the responsibilities of resident care regarding incontinence. Staff 1 (S1) stated that “care staff will perform the checks every two hours, we have rounds with residents in rooms.” Interviews with residents revealed that Resident 1 (R1) may not receive incontinent care that matches their needs. R1 stated that “Staff put a diaper on me because most of the time they don’t check on me. I can go to the bathroom by myself; I just can't transfer to my chair myself because I'm not strong enough.” R1 continued by stating they have experienced times when they were assisted by staff to go to use the toilet, but staff did not come back to assist R1 out of the bathroom when they used the signal system. Interviews with Outside Sources revealed parts of the incontinent care provided by staff that are not meeting the needs of R1. Outside Source 2 (OS2) told the LPA there were times when R1 was not cleaned properly after receiving care from the facility. Outside Source 3 (OS3) stated while taking care of R1’s incontinence needs, they noticed that care staff did not properly clean R1. OS3 told the LPA that there was a time when they were taking care of R1 that they discovered feces in R1's genitals due to the care the facility staff provided. Records review revealed that in a pre-placement appraisal dated May 2025, under the “Services Needed” section, it is indicated that R1 needs continence care. In a medical assessment dated October 2025, R1’s report under the “Overall Physical Health” section shows that R1 does not require care for Bowel or Bladder incontinence, however there is a note saying that they wear briefs for accidents; this corroborates resident interviews. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are 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 ED Mike McCoy, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued on LIC9099C, Page 3) (Continued from LIC9099C, Page 2) On 12/09/2025 it was alleged that "Staff do not respond to resident’s calls for assistance” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, " Staff do not respond to resident’s calls for assistance," it was alleged that facility staff are not answering Resident 1’s (R1) alerts through the facility signal system in a timely manner. Interviews with staff revealed that staff are aware that call times may vary based on the time of day including scheduled meals at the facility. Staff 1 (S1) stated that during meal times, it will take staff longer to answer the signal system. S1 confirmed that staff will communicate with each other to address needs based on priority and answer all residents’ signal alerts. Facility staff stated unanimously that signal calls should be answered within 10 and no more than 15 minutes. Interviews with residents revealed that when Resident 1 utilizes the facility’s signal system, it is not always answered in a timely manner. R1 stated in an interview with the LPA, “One time, I got left in the bathroom for 2 hours and I had my watch on so I was able to time it. Even when I pull on the signal chord, it doesn’t do any good." Interviews with Outside Sources revealed that facility staff are not consistent with answering signal alerts. Outside Source 2 (OS2) stated that during their visits with R1, they have used the call system with no answer from facility staff. Outside Source 3 (OS3) told the LPA that during their visit with R1 that facility staff did not show up for some time between 1 and 2 hours. This corroborates resident interviews. Records review revealed the facilities signal system record for R1 from September to December of 2025 was used 490 times and over half of the recorded durations of the signal lasted more than 15 minutes. According to the record, over 60 instances during the Sept-Dec period took staff over 1 hour to respond and/or resolve the alert. LPA Observations revealed that during the interview with R1, the LPA initiated the signal system in the facility to check response times. The LPA timed the staff and no one arrived after 20 minutes. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are 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 ED Mike McCoy, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.