Complaint·August 26, 2025

During the visit, LPA reviewed R6’s call button response log and interviewed R6. According to R6, staff are responding to his/her call button on time. In addition, R6 indicating that he/she understands and is not complaining when staff take longer to respond at times as staff are assisting other residents. Based on R6’s call button response log, staff do respond timely to R6’s calls. Based on interviews conducted and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Regional Sales Specialist, Jessica Wiggins and a copy is provided. A civil penalty of $250 is issued today for a repeat violation within the last 12 months. The facility has received a deficiency for California Code of Regulations, 87465 Incidental Medical and Dental Care in relation to the med-errors on 2/27/25, 4/29/25, 5/6/25, and 7/1/25. Regarding the allegation, facility failed to report incident to CCLD, according to the reporting party, the facility is not reporting R1’s med errors to CCLD. During the visit, LPA reviewed records and interviewed staff. Based on records, it was observed that the facility has not submitted any incident reports to CCLD regarding R1’s med-errors that occurred on 8/8/25 and 8/10/25. According to staff interviewed, they believed that an incident report did not have to be submitted because although the med-errors occurred, it was caught by R2 and fixed by the med-tech. Regarding the allegation, facility failed to ensure resident's beds were in good repair, according to the reporting party, Resident 3’s (R3’s) and Resident 4's (R4’s) bed collapsed because the maintenance director did not assemble the beds correctly. During the visit, LPA interviewed staff, R3 and R4. According to R3, he/she was sitting on the side of the bed that was provided by the facility, when the bed's slate underneath the mattress slipped, causing the mattress to collapse on the floor. LPA was unable to interview R4, however according to staff interviewed, they indicated that R4's bed did not collapse, R4 just rolled out of it. In addition, according to staff interviewed, R3's bed was not able to hold his/her weight causing the slate to shift and the mattress to collapse. Although LPA was unable to interview R4, R3's bed was not in good repair, causing R3's bed mattress to collapse. Based on the interviews conducted, records reviewed and information collected, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Regional Sales Specialist, Jessica Wiggins and a copy is provided with appeal rights. A copy of the civil penalty is provided.