complaint·April 8, 2026

Witnesses 1 and 2 (W1 and W2) from the local emergency response agencies reported receiving calls from the facility that did not meet medical emergency criteria, including multiple calls per day during early January. One witness stated residents were left on the floor for responders to lift, and that these calls were categorized as public service rather than medical emergencies. On 01/23/2026 at approximately 1:35 p.m., LPA Partoza received a phone call from Executive Director/Administrator (S1) regarding the above allegation. During the phone conversation LPA inquired if S1 is aware of the Provider Information Notification (PIN) 25-06-ASC. S1 stated that he/she is unaware of the PIN. LPA proceeded to read PIN 25-06-ASC to S1 and discussed the PIN with S1. LPA provided technical assistance to S1 with accessing the CCLD website PIN portal. LPA interviewed the following staff (S1 to S8) on the following dates, 01/23/2026, 02/06/26, 02/27/2026 and 03/26/2026. S1 to S8 stated that the facility is non-medical, has no 24/7 nurse, and does not maintain lift equipment. S1 to S8 stated, staff provide one person assistance and are not authorized or trained to take vital signs. Staff S1, S3 to S7 stated that staff calls 911 for unwitnessed falls, head strikes, new pain, and when residents were unable to bear weight or assist with transfers. Staff S1, S3 to S8 stated that 911 was contacted for lift assistance in non-injury situations due to size, weight or gender disparities between staff and residents and the absence of lift equipment. S1 to S8 stated that the facility does not have lift equipment and provides one person assistance. On 02/27/2026, LPA Partoza interviewed four residents (R1–R4). R1 and R4 declined to be interviewed. R2 and R3 stated they required lift assistance in the past and could not be lifted by staff. R3 stated he/she began using personal lift equipment to avoid 911 calls. Based on the documents reviewed, eleven 911 calls were made between 01/04/2026 and 01/31/2026. On 01/10/2026, two calls were made, one of the calls had no corresponding documentation. On 01/11/2026, two calls were made for two residents, followed by a third call on 01/12/2026 for one of the residents at the physician’s request. page 2 of 3 On 12/27/2025, two calls were made to 911 and both residents were transported to the emergency room. Additional documented 911 calls identified as lift assists occurred on 08/09/2025, 10/31/2025, 11/15/2025, and 12/23/2025, that was documented by staff on the incident report as unwitnessed falls and residents had no injury, declined hospital transport, or were unable to stand without assistance. Based on the Provider’s Information Notification (PIN) 25-06-ASC issued on 06/24/2025, it states, “For circumstances that do not constitute an imminent threat, as outlined in California Code of Regulations (CCR) Title 22, Section 87465 (g), Incidental Medical and Dental Care Services, as a best practice, licensees may consider alternative options for obtaining medical attention. Evaluation by an on site appropriately skilled professional or other licensed healthcare professional, Program of All-inclusive Care for the Elderly (PACE) provider, hospice care to name a few (pg. 2). “Lift Assists” occurs when a resident needs help with mobility or transferring from one position to another, but there are no signs of injury or medical concern. Licensees are responsible for ensuring that sufficient staff are available to meet resident’s needs and staff are adequately trained and equipped to assist residents with lift assistance, mobility and transfers safely, and without the need for emergency services, as long as the resident is not injured or experiencing health concerns…Thus, calling 911 solely for lift assist is not appropriate if it has been determined that the resident has not sustained any injury (pg. 4).” Based on document review and interviews, the facility contacted 911 for lift assistance in non emergency situations on the following dates 08/09/2025, 10/31/2025, 11/15/2025, and 12/23/2025. Staff reported that 911 was contacted when residents could not assist with transfers due to the absence of lift equipment and the facility’s one person assist staffing. PIN 25-06-ASC (06/24/2025) states that 911 should not be contacted solely for lift assist when no injury is present and that licensees are responsible for ensuring staff are trained and equipped to perform non-injury lift assists. Based on LPAs observations, interviews which conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22 87465 (g) is being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Maddalena Chavez, a copy of the report and appeals rights were provided. page 3 of 3 end of report