complaint·February 27, 2026

Staff are not properly supervising a resident who is a fall risk. During staff interviews, S2 stated it is very rare that we have only one care staff. S2 stated maybe once a month, but not usually. S4 stated the staff are not checking on the residents every couple hours. S4 stated the management put fifteen residents to one care staff. S4 stated when I have two fall risk one in the front and one in the back, which one do I go to first. Staff reported a resident fell when I was working by myself, a resident fell when I was at the other end of the building and didn't hear the alarm. Staff reported this caused the resident to be left on the floor for an extended period of time. Staff stated we have pull alarms attached to residents that are a fall risk, It sounds a loud alarm. Staff stated the pendent report goes to all staff with a tablet. S3 stated the medication technicians are busy with the medication and don’t have time to help the care staff. S3 stated we were working double shifts. S3 stated the alarms the residents wear on their person didn’t work, the tablet batteries were dead half of the time. During the investigation S2 and LPA went to R2s room to check the sound of the call button. Staff turned on the alarm while LPA went to the opposite end of the facility, LPA could not hear the alarm. It was reported the call button usually bought was unavailable and the new call button alarm was not as loud. S2 found an old facility call button, LPA and S2 tested the alarm and it could be heard at the opposite end of the facility. Staff took away resident's personal belongings. During staff interviews the Administrator reported an individual called and ask staff to take R1’s phone as they were calling them too often. The Administrator informed the individual they could not take R1s phone as it violated the residents’ personal rights. Staff stated the individual called back and ask another staff to take R1’s phone because R1 was calling too often and the staff took the phone and placed the phone in the staff work area. Staff stated this happened months ago. Staff stated It may have been a few hours that we had possession of the phone before it was returned to the resident. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. An exit interview was conducted and appeal Rights provided.