complaint·May 24, 2023

Staff confirmed that it typically took approximately 30 minutes, to respond to residents, especially when they are assisting other residents. A review of facility records showed resident #1 (R1) Physician’s Report dated July 2021 revealed that R1 was independent and needed no assistance with transferring. However, during staff interviews, it was revealed that R1 needed a reassessment to be completed to show R1 needed a higher level of care that included assistance with transferring. Staff schedules showed there were three working shifts for each unit, assisted living and memory care. The first shift for the assisted living unit, 6:00 AM – 2:00 PM, typically scheduled two personal care assistants and one medication technician. It was infrequent to see two medication technicians assigned with two personal care assistants during the same shift. The following shift, 2:00 PM – 10:00 PM, usually had two personal care assistants and one medication technician scheduled. Schedules showed one medication technician and one personal care assistant scheduled at least twice per week. The last scheduled shift, 10:00 PM – 6:00 AM, only had one medication technician and one personal care assistant scheduled twice per week and only one medication technician the remaining of the week. There were times on the schedule that there were no medication technicians or personal care assistants scheduled in the assisted living unit on the last shift. During the visit on March 21, 2023, the current resident census was 97; 16 residents in the memory care unit and 81 residents in the assisted living unit. There were six residents who were on hospice services. When LPA toured the facility, LPA observed only one caregiver in sight on the second floor assisting a resident with their meal. Once that caregiver left, there were no other staff observed in the vicinity. LPA was able to tour the area for approximately 30 minutes. LPA observed a resident attempting to leave their room who needed assistance with no staff to assist. LPA was able to assist resident to keep their door ajar while they exited their room. There was a second resident who needed assistance with finding the elevator and looked for an elevator or staff to assist. LPA guided the resident to the elevator as there were no staff present. Based on the information obtained, there is sufficient evidence to support the allegation. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and resident interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Executive Director Emily DelaBarre. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director DelaBarre at the conclusion of the visit. The signature below confirms the receipt of these documents.