complaint·May 29, 2025

Continued from LIC9099 On the allegation: “ Due to lack of supervision, resident hit another resident causing injury " The Responsible Party (RP) expressed concern that they believes the staff to resident ration is poor or inadequate. During the initial visit, LPA Conway conducted interviews with the two (2) residents involved in the reported incident. However, due to both individuals having a diagnosis of dementia, neither resident was able to clearly recall or articulate the events that took place on that day. LPA interviewed facility ED stating that she was not present at the facility when the incident occurred but reported that staff responded to the residents promptly. During staff interviews, it was consistently reported that the facility is experiencing ongoing staffing shortages, which has made it increasingly difficult for caregivers to adequately attend to all residents' needs. Staffs acknowledged that facility policy mandates 15 minute safety checks, however, these are not being properly conducted due to insufficient personnel, stating that it is not possible to conduct these checks as require and as a result, residents are at risk of injury. In fact, due to the current staffing situation, there have been multiple incidents involving resident hitting other residents and falls that required hospitalization. Additionally, staff reported that certain caregivers are frequently observed using their personal phones during work hours, resulting in inadequate supervision and reduced attention to residents' needs and safety. Based on information and the evidence gathered during the course of the investigation, there is sufficient evidence to determine that due to lack of supervision a resident hit another resident causing an injury. Therefore, the above allegation “ Due to lack of supervision, resident hit another resident causing injury ” 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. An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.