complaint·October 13, 2025

The Generation Program Director (GPD) explained residents in memory care don’t typically receive a call pendant due to their cognitive ability. However, R1 was provided with a call pendant due to having private companions. If assistance was needed prior to the staff making their rounds, then the private companion would push the pendant and alert staff. The private companions do not provide care, the facility staff are responsible for the residents’ care needs. The facility’s policy for their memory care unit is that staff check residents according to their care plan, as needed, and/or every 2-3 hours per shift. The GPD explained that most residents are asleep at night. However, some residents require incontinent care, which is provided by the NOC shift staff. The NOC shift will provide incontinent care at the beginning of their shift, the middle of their shift, and at the end of the shift. Staff will also provide additional care if needed. GPD stated residents have a care plan, which is followed by the staff, as each resident has different needs. The Outside Source stated staff did not check on R1 on the evening of 10/04/25. The memory care unit has 2 staff on the NOC shift: 1 Medication Technician (med tech); and 1 caregiver. In the memory care unit during NOC shift the med tech steps into the role of a caregiver and provide care to residents. The facility will also use caregivers from their Assisted Living portion of the facility when needed. Staff #1 (S1) was working the NOC shift on 10/04/25. It was determined that S1 was under the assumption that due to R1 having a private companion, there was no need for a routine check. The GPD explained to S1 that all residents are checked regardless. The GPD also explained S1 was under the impression that if R1 needed assistance, the private companion would use the call pendant. Based on evidence, S1 did not check in on R1 during the night of 10/04/25. A review of R1’s call pendant log for 10/04/25 indicated the pendant was activated at 5:03pm and 5:07pm, there were no other calls for assistance indicated. S1 has been made aware by management that all residents must be checked, regardless of private companions. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Senior Business Office Director, Reika Villagomez Marron whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]