complaint·February 19, 2025

Continued on LIC 9099-C Regarding allegation “Staff are engaging in behaviors that put the residents’ health and safety at risk” it has been reported that staff members have exhibited inappropriate conduct while on duty during the PM shift and nocturnal (NOC) shift. Interviews with the Executive Director (ED) revealed that management is not aware of staff playing loud music or leaving the floor unsupervised during the NOC shift. Staff interviews did not corroborate these allegations. Residents interviewed indicated that some residents occasionally hear loud noises during the PM and NOC shift; however, they were unsure whether the sounds were from staff, residents playing music or singing or televisions. During the investigation, the LPAs inspected the staff break room for any prohibited items but found no evidence to support the allegations. Based on the information obtained during the investigation the LPA does not have sufficient evidence to corroborate the allegation. 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 “Staff are engaging in behaviors that put the residents’ health and safety at risk” is deemed UNSUBSTANTIATED at this time. Exit interview conducted, copy of this report and was provided. Continued from LIC 9099 Regarding allegation “Staff did not respond to residents’ call for assistance in a timely manner” it has been reported that during the night shift, residents pulling the emergency cord to request assistance from staff had to wait approximately one (1) hour before being attended to by a staff member. LPAs interviewed staff and residents related to the facility’s pull cord system and response time. The facility contains a pull cord system; each resident room has one cord in the bed area/living space of the room and a second pull cord in the resident bathroom. When a resident pulls the cord, a light illuminates outside the resident room and on a switch boards located at the front desk and in the dining room. Interviews with the ED revealed that staff members are trained to assist residents within ten (10) to fifteen (15) minutes after a call cord is pulled. The most recent in-service training for call light monitoring was conducted on 08/2024. Additionally, the ED stated that after a resident communicated concerns about long response times, a group chat message addressing call cord wait periods was sent to all staff via text on 12/16/2024. This message served as a reminder that is unacceptable for residents to wait longer than fifteen (15) minutes for assistance. Interviews with staff revealed that caregivers may become occupied when multiple residents pull the emergency cord simultaneously. In such cases, staff prioritize responses based on the urgency of each call, which may result in less urgent request experiencing longer wait times. However, staff members stated they make every effort to assist all residents within fifteen (15) of the initial call. Interviews with residents revealed that seven (7) out of nine (9) residents reported experiencing long wait times across all three shifts after pulling the call cord. Most residents stated that response times could sometimes take forty-five (45) minutes to an (1) hour. Additionally, some residents expressed concerns that having only two (2) caregivers on duty is not sufficient to meet the need of the entire assisted living unit. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that “Staff did not respond to residents’ calls for assistance in a timely manner” is deemed SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation “Staff did not treat residents with dignity and respect” it has been reported that staff members have been yelling at residents, despite concerns being brought to management, issue has not been addressed. Interviews with the ED revealed that management is not aware of any instances of staff mistreating or disrespecting residents. The ED stated that no residents or visitors have reported such concerns to management. Staff interviews presented mixed responses – some staff members reported witnessing colleagues speaking loudly or rudely to residents, while others denied any instances of mistreatment or disrespect. Additionally, those who denied such behavior stated that they had not witnessed any abusive conduct toward residents in care. Interviews with residents and family members revealed concerns regarding staff conduct. Resident #1 (R1) reported being spoken to disrespectfully, with sarcasm and dismissiveness by a Staff #1 (S1). Resident #2 (R2) stated that they have occasionally been handled roughly during transfers by Staff #2 (S2). Resident #3 (R3) reported being criticized by a staff member regarding their weight by Staff #3 (S3). Furthermore, several residents expressed concerns that the new hires do not appear to be receiving proper training. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that “Staff did not treat residents with dignity and respect” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.