complaint·October 30, 2025

...Continued from 9099 The two (2) NSPs also state that for Toileting and Transfers R1 will require a “two (2) person assist”. During review of facility staff schedules LPA observed that only one (1) Caregiver (CG) was assigned to the entire Assisted Living unit. The facility currently has a probationary license. As part of the Stipulation and Waiver, and Order dated 6/30/2022, the License understands that facility staff must be hired in numbers necessary to meet the needs of the residents. To that extent, each Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Medication Technician (MT) will not be a direct care staff but may provide support when not distributing medication. LPA reviewed the facility call system response logs from 7/1/2025 to 8/7/225 and observed that within this time frame there were five (5) instances where R1 requested assistance, and the response time exceeded fifteen (15) minutes. Additionally, there is video showing R1 being moved to a wheelchair positioned at the base of the bed in front of the television at approximately 5:40 AM. Resident R1 was not moved back into their bed until approximately 1:32 PM when the video shows a single (1) staff member moving R1 into bed although their NSP states that R1 requires a two (2) person assist for transfers. Based on LPA’s observations and record review, 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 on 11/19/2024, 5/6/2025 and 7/24/2025. As this repeat deficiency occurred within one (1) year of the previous citations, a Civil Penalty of $1000.00 will be assessed. Exit interview conducted. Copy of LIC-9099, LIC-9099-C, LIC-9099D, Plan of Corrections, LIC-421IM and Appeal Rights discussed and provided to Executive Director Rodriguez. Signature on form confirms receipt of documents. ...Continued from 9099 Additionally, LPA observed that the same four (4) Caregivers were current and have completed the required four (4) hours of additional monthly training as part of the Stipulation and Waiver, and Order dated 6/30/2022. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges the facility unlawfully evicted resident R1. Witness reported that the facility was requiring resident R1 to move from Assisted Living (AL) to Memory Care (MC) due to a change in R1’s cognitive function. The witness further stated that they asked the facility for proof, in writing, of the cognitive change as diagnosed by a licensed medical professional. Resident R1’s Residence and Care Agreement, section G Change of Level of Care states, “If we determine that you need a different level of care than that which you are currently receiving, we will provide you and your responsible person, if applicable, with written notice of the change.” The facility did not provide proof of any cognitive change for R1. During interviews facility staff members S2 and S3 stated that no written notice was given as they were not requiring that resident R1 move to Memory Care. Staff members S2 and S3 stated that the move would be voluntary. Neither the facility nor the witness was able to provide any documentation stating that the facility was requiring that resident R1 be moved to Memory Care. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy of report discussed and provided to Executive Director Rodriguez. Signature on form confirms receipt of documents.