Complaint·July 30, 2025

(Continue from LIC9099) According to the complaint, residents were receiving their medications late due to a shortage of staff available to administer them. It was reported that between February and May 2024, the facility experienced a shortage of medication technicians and direct care staff. However, no specific details were provided regarding which residents were affected or the specific dates and times when medication was administered late. Findings CCL conducted interviews with staff, residents, responsible parties, and external sources, all of which consistently corroborated both allegations. Staff interviews revealed ongoing concerns regarding inadequate direct care staffing during the period in question. Management acknowledged the use of external staffing agencies to fill gaps and compensate for staffing shortages. During visits conducted on June 3, 2024, and April 10, 2025, LPA observed the Executive Director acting as a medication technician due to staff shortages. Interviews with staff and residents confirmed that the Executive Director and other non-direct care staff were frequently reassigned to cover care shifts. As a result, medication administration was often delayed. While no adverse health outcomes were reported due to delayed medication, residents’ other care needs were not consistently met. Interviewees stated that services such as incontinence care, showering, grooming, laundry, and housekeeping were often delayed or incomplete. For example, maintenance staff were observed doing laundry, and housekeeping staff were assisting with food service duties. Management and staff indicated they were making efforts to meet residents’ needs but acknowledged that there were not enough staff available to maintain adequate care. It was further explained that the facility was experiencing challenges in remaining competitive within the industry and had to rely heavily on outside staffing agencies. As of May 2025, the facility is under new management. The current administration has prioritized increasing staffing levels to ensure resident care needs are met. Follow-up interviews with staff, residents, and external sources confirmed that current staffing is adequate. (continue at LIC9099C) (Continue from LIC9099C) Conclusion Based on the evidence obtained through observations and interviews, CCL substantiates both allegations using the preponderance of evidence standard. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and are detailed on the LIC 9099-D form. A Plan of Correction (POC) was developed in coordination with ED EJ Lewis. An exit interview was conducted with ED Lewis, who was provided with copies of this report, the LIC 9099-D Deficiency Report, and the LIC 9058 (03/22) Licensee Appeal Rights.