complaint·July 24, 2025

...Continued from 9099 The facility is under Stipulation and Order and Waiver (Stip) as of 6/30/22. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, page four (4), line items 26-27 and page five (5), line items 1-5, each Memory Care unit and Assisted Living unit will be staffed independently such that the units do not share direct care staff. The medication tech will not be a direct care staff but may provide support/backup when not distributing medication…and staff breaks, and lunch shall be staggered so there is adequate staff coverage. In addition, page five (5) line items 5-7 state that a census of each unit and any two (2) person assist be identified. During the investigation, LPA reviewed staff schedules from 6/18/2025 through 7/2/2025 for Memory Care building 1 (MC1), Memory Care building 2 (MC2) and the Assisted Living building (AL). LPA observed that there was only one (1) Caregiver scheduled for MC2 and AL per shift during this time frame. LPA further observed that on the two (2) person assist census dated 6/13/2025, MC2 residents R2 and R3 were listed as needing a two (2) person assist; however, on the two (2) person assist census dated twelve (12) days later on 6/25/2025 the same two (2) residents were not listed as requiring a two (2) person assist. During records review, LPA observed that there was no change in conditions for these two residents. Additionally, resident R4, who lives in assisted living was listed as requiring a two person assist. During interviews conducted with staff, both S1 and S2 stated that MC2 Resident R1 displays aggressive and disruptive behaviors that require a staff member to address and or redirect resident. During this time, a second (2 nd ) staff member is required to monitor the other residents. During charting note review, LPA observed fourteen (14) instances of aggressive behavior from R1 towards staff and other residents between the dates of 6/4/2025 to 7/1/2025. Based on LPA record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. The facility was cited for the same deficiency on10/16/2024, 11/19/2024 and 5/6/2025. As this repeat deficiency occurred within one (1) year of the previous citations, a Civil Penalty of $1000.00 will be assessed.