complaint·November 20, 2025

Continued from 9099... staffing ratio requirements. However, the facility must be able to meet the needs of residents. So, during investigation LPA reviewed the care plans and medical assessment for all 23 Memory Care residents. Of the 23 residents: · Ambulation: 6 require extensive assistance, 2 require moderate assistance. · Transferring: 4 require extensive assistance, 4 require moderate assistance, 2 require a two-person assist. · Bathing: 11 require extensive assistance, 4 require moderate assistance. · Grooming/Dressing: 8 require extensive experience, 6 require moderate assistance. · Toileting: 4 require extensive assistance, 8 require moderate assistance · Wandering/Sundowning behavior: 6 are reported to have this behavior · Fall risk: 3 are identified as being a high risk, 1 identified as a moderate risk, and 2 identified as low risk During investigation, LPA conducted interviews with witnesses. Four (4) out of six (6) witnesses report that facility's NOC shift is understaffed. LPA received report that medication was not made available to a resident that needed it during NOC shift because there was not a Med Tech or caregiver on duty that could dispense medication. LPA reviewed Memory Care staff schedule. Review of staff schedule shows that at least one Med Tech and 2 caregivers are scheduled each NOC shift. However, on some days schedule shows only one caregiver and one Med Tech for both Assisted Living (AL) and MC; other days it shows only a Med Tech. Per Admin, this is because the facility is utilizing caregivers from registry. Admin states facility needed to hire a NOC shift caregiver permanently and while they were conducting interviews and reviewing candidates for hire they used registry for temporary staff coverage. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D Conitued on 9099C(2)... Continued from 9099C... Note * Admin advised LPA during delivery of findings that facility has addressed incontinence care with NOC shift caregivers. Admin was made aware of residents incontinence issues not being met due to employees inadequate ability to identify needs of residents. Upon learning of issue, Admin immediately addressed caregiver inadequacies by terminating their employment. Admin has since filled the open positions resulting from termination and trained new staff on proper incontinence care. LPA verified records confirming as such, Admin is also adding another caregiver to NOC shift so that ideally there are 2 Med Techs and 2 caregivers for the NOC. Exit interview conducted with Admin and a copy of this report given. Appeal rights given.