complaint·March 25, 2026

Continued from LIC 9099 Regarding allegation of “Uncleared staff worked at facility” it was reported that Individual #1 was conducting repairs inside and outside of the facility despite not being an employee and lacking clearance or association with the facility. Interviews conducted revealed that I1, who is a relative of the administrator, was present at the facility to perform random maintenance work. I1 was present only during normal waking hours for a limited duration and did not provide care or supervision to residents in care. Based on the information gathered during the investigation, the allegation of “Uncleared staff worked at facility” is deemed UNSUBSTANTIATED, as there is insufficient evidence to support that I1 was working in a staff capacity. No citations issued. Exit interview conducted. A copy of the report was provided. Continued from LIC 9099 Regarding allegation “Facility administrator is not present at the facility an adequate number of hours” It was reported that the Administrator does not regularly visit the facility due to distance, and is present approximately once a week and at times not at all during certain weeks. At approximately 11:20 A.M. a phone interview with the Administrator revealed that they were attending a meeting and were unable to arrive at the facility prior to 4:00 P.M. The LPA reviewed the LIC 500 Personnel Report, which indicates that the Administrator is scheduled as “on call” and assigned to work seven (7) days a week during evening hours from 07:00 P.M. to 07:00 A.M. However, the Administrator was not present on today's visit, the prior annual visit conducted on 01/23/2026, or during the reported scheduled hours. Interviews further revealed that the Administrator was last physically present at the facility several weeks ago, and it was also indicated that the Administrator’s presence at the facility was inconsistent. Additionally, it was reported that the Administrator’s primary residence is in Temecula, CA. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Facility administrator is not present at the facility an adequate number of hours” has been SUBSTANTIATED at this time. Regarding allegation “ Facility was understaffed during a medical emergency ” it was reported that a recent incident occurred in which the sole caregiver on duty experienced a medical emergency and was transported to the hospital. The Reporting Party expressed concern that, due to the Administrator residing hours away, individuals who were not scheduled employees temporarily provided care and supervision to residents until the Administrator arrived several hours later. An interview with the Administrator confirmed that on the day of the incident, Staff #1 (S1) experienced a medical emergency and was transported to the hospital. However, the Administrator requested help from a Family Member (FM) to provide temporary supervision until their arrival and that a visitor also remained at the facility for approximately 30 minutes to assist. The LPA reviewed the Guardian System and revealed that FM is fingerprinted cleared and associated to the facility. The Administrator further stated that the facility currently employs two (2) caregivers who work alternating live-in schedules for consecutive days. At the time of the incident, the relieving caregiver was unavailable due to being out of the area. Interviews with staff indicated that the current residents are generally easy to care for and do not require extensive assistance. Continued on LIC 9099-C Continued from LIC 9099-C However, additional interviews revealed that when only one (1) caregiver is on duty, residents may experience delays in receiving assistance when the caregiver is occupied with other tasks. It was also reported that residents are sometimes instructed to wait for assistance while the caregiver completes chores or assists another resident. During the visit, the LPA observed that while the sole caregiver assisted one resident with bathing and grooming for approximately 45 minutes, the other resident remained alone in the living room without supervision. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “ Facility was understaffed during a medical emergency ” has been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Facility Designee was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.