Complaint·March 10, 2026

Page 2 of 2. Three out of five staff stated there are issues with system not clearing the resident’s call button/pendent which will be documented on the call button/pendent report as not answered. Two out of five staff stated there have been issues where residents pushed the call button and the notification is not logged into the system. Three out of five staff stated there haven’t been issues with responding to residents in a timely manner but they are aware that emergencies do exist like responding to a medical intervention or paramedics reporting to the facility which will delay in responding to resident’s call button. Five out of five staff stated the staff will routinely check on the residents throughout the day, so they are able to address their concerns in a timely manner without relying on the call button/pendent. On 8/19/2025, the Department interviewed three residents (R1-R3). Two out of three residents refused to be interviewed. Resident (R2) stated there are no issues with staff responding to the resident’s call buttons. R2 stated he/she knows how to use the call button pendant and stated the staff will respond within approximately 10 minutes. During the interview, R2 pressed the call button, and LPA Rai observed the response time as 9 minutes, within 10 minutes time frame. Based on review of the response times of call bell pendants for the month of July 2025, the average wait time was within 20 minutes, from when the call button/pendant was pressed to when the call button/pendant was cleared. Based on interviews conducted of the 9 residents whose wait time on average was over 20 minutes, 5 out of 9 residents had moved out of the facility during the investigation. LPA Rai interviewed 4 residents (R4-R7) and 4 out of 4 residents stated there were issues of call buttons being answered over 20 minutes in July 2025 wherein the residents required assistance with ADLs and not medical assistance. All 4 residents stated there were issues with staff not responding to the call bell pendents for over 20 minutes but the staff have improved and they are answering the call bell/pendents more quickly. LPA Rai reviewed no requirement stated in the facility’s Admissions Agreement or Resident Handbook in regard to staff response time for resident’s call buttons/pendent. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided. Page 2 of 2. Six out of six staff stated the managing director did come to the facility and covered the shift. Three out of six staff members were aware there were two managing directors on the floor administering medications. Three out of six staff members stated there was a delay in residents receiving medication, but they received the medication before 11am on 7/27/2025. On 8/19/2025, the Department interviewed three residents (R1-R3). Two out of three residents refused to be interviewed. Resident (R2) stated there were no issues with medications, including the medications given on 7/27/2025. R2 stated the staff will come back if R2 is busy receiving the medication. Based on review of facility’s Program Plan on Medication Management, page 12 out of 16 states medication should be distributed based on prescriber orders. LPA Rai reviewed no requirement stated in the facility’s Admissions Agreement or Resident Handbook in regard to time response for distributing medications. Based on review of the Time Variance Report at 5 random residents Medication Administration, LPA Rai reviewed the medication administered on 7/27/2025. LPA Rai reviewed managing director’s signature on administering the mediations on 7/27/2025 to the residents and note was made that the medication was given but was charted late on the resident’s file. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Ida Gemignani-Stearns and a copy of the report was provided.