Complaint·January 28, 2026

LPA observed the main and service elevator permits with a date of inspection of 12/5/2023, and an expiration date of 12/5/2024. The permits were issued by the State of California, Department of Industrial Relations, Division of Occupational Safety & Health. On 1/8/2026 the Department interviewed the Administrator (ADM) Kippie Castronovo, 5 Staff (S1 to S5), and 3 Residents (R1 to R3). ADM states the two facility elevators (main and service) ‘have issues.’ ADM states the facility main elevator was out of service sometime in late December 2025 for approximately 8 days. ADM states the main elevator was repaired and operational after this incident in December 2025. ADM states the main elevator broke down again in early January 2026. ADM states maintenance is notified any time the elevators are not working. On 1/8/2026 the Department interviewed 5 Staff (S1 to S5). 5 out of 5 staff he/she is aware of the facility elevators breaking down. 3 out of 5 staff state the facility repairs the elevators any time the elevators are broken down. 2 Out 3 did not provide additional information. On 1/8/2026 the Department interviewed 3 Residents (S1 to S3). 3 Out of 3 residents state he/she is aware of the facility elevators not working sometimes. 2 Out of 3 residents state the facility repairs the elevators when they are broken down. R3 did not provide additional information. Review of facility elevator service logs, a ‘Callback’ was placed on 1/3/2026 at 12:54PM, with ‘End Date’ of 1/3/2026 1:30PM. The log notes labor hours as 1 hour and 15 minutes for the repair. LPA also observed 'Callback' for 12/17/2025 at 7:59AM with 'End Date' of 12/17/2025, with time of 30 minutes, and labor 45 minutes, a 'Callback' on 12/18/2025 at 6:29PM, with an 'End Date' of 12/18/2025 at 8:15PM, with 4 hours and 45 minutes of regular time, 45 minutes of labor. Facility administrator and staff are falsifying staff training records It has been alleged that that facility ADM and staff are falsifying training records. On 1/7/2026 the Department interviewed the Reporting Party (RP). RP states the ADM falsifies staff training records so ‘she would not have a bad number, reflect bad on her as a manager.” RP states the ADM “made” him/her participate in falsifying staff training documents for the past 7 months. Page 2 of 3 On 1/8/2026 the Department interviewed 5 Staff (S1 to S5). 4 out of 5 staff he/she completes his/her own training online. 4 Out of 5 staff state he/she logs into the training using his/her own personalized login information. LPA was unable to ask S5 this question due to S5 being called away to assist a resident. LPA reviewed 7 random staff training records. 7 Out of 7 staff trainings document “hours, dates, modules, status, grade, completion date.” 2 Out of 7 staff training records note individual user information for staff. 5 Out of 7 staff training records only note the staff name. Staff training included but not limited to dementia care, essential resident rights, fire safety. Facility is not conducting emergency drills On 1/7/2026 the Department interviewed Reporting Party (RP). RP states he/she observed the ADM tell another staff member that she ‘falsified’ the emergency training records. RP states this occurred about 1 or 2 months ago. On 1/8/2026 the Department interviewed 5 Staff (S1 to S5). 1 Out 5 staff state he/she has participated in an emergency drill in 2025. 3 Out of 5 staff stated he/she has not participated in an emergency drill but also stated he/she was not sure if they participated in an emergency drill. S4 states he/she was not sure because he/she only works 3 days a week at the facility. LPA was unable to ask S5 this question due to S5 being called away to assist a resident. Review of facility emergency drill logs note the facility conducted emergency drills each month from January 2025 to December 2025, with an in-service sign in sheet signed by facility staff. This agency has investigated the complaint alleging facility does not ensure facility elevators are maintained in good repair, facility administrator and staff are falsifying staff training records, facility is not conducting emergency drills. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with Executive Director (ED) and a copy of this report was provided. Page 3 of 3 END OF REPORT