complaint·September 25, 2025

explanation or reasons at that time. Based on a review of the eMAR system utilized by this facility at this time, the section where notes and information would be entered if the medications were missed, refused, or not given did not have any information entered at this time. Based on interviews conducted during the course of this investigation, it was learned that if a date where the required initial and notes were not present in the eMar system then it would be considered that the medication was not properly dispensed to the resident at that time and missed for that timeframe. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. A civil penalty in the amount of $1000 was issued on the following LIC 421IM to this facility, and it's representative, at this time. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview Based on a tour of the memory care unit, Traditions, it was observed that there were not any foul or bad odors detected at the time of this facility tour. A sample review of the facility resident bedrooms, as well as the resident restrooms, was conducted. Based on this review, there were not any foul or bad odors detected at the time of this facility tour. Based on a review of the facility theft and loss policies and procedures, it was observed that steps were put into place to address any incidents of loss by the residents and the facility's response in addressing these incidents. It was observed that an inventory sheet was also completed, if accepted by the resident and their responsible party on the Admissions Agreement, to inventory all personal belongings upon admission to this facility. This document was also updated, as necessary, in order to safeguard the resident and their belongings. This document also protected the facility in the cases of false allegations of theft or loss suffered by the facility resident. This facility was observed to have completed the required inventory log sheets for the residents in care at this time. Based on a review of the facility call log system, which was used by the facility residents to signal for help or assistance, it was learned that the response time for facility care staff to receive, respond, and reset the call for assistance was between 5-10 minutes. It was observed that there were incidents that were recorded outside of this timeframe but were reviewed on a case by case basis taking into account the time of day, staffing, and nature of the activation for service. It was observed that the response to the calls for service by the facility residents were being met for the 5-10 minute requirement at this time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interview