complaint·July 11, 2025

Continued from LIC 9099-C It was reported that “Licensee does not ensure staff are adequately trained” as it was alleged that temporary agency staffing does not appear to be trained adequately.” Information gathered during the course of the investigation revealed that, due to ongoing staffing shortages, management made the decision to utilize a temp agency to fill in for staff who resigned or called out due to illness. Resident interviews revealed that both the temporary agency caregivers and the facility’s current and recently hired staff are not adequately trained to meet their care needs. Residents consistently reported that staff often appeared unsure of how to assist with their activities of daily living, such as bathing, dressing, transferring and toileting. Several residents expressed concerns that staff frequently did not know what to do or how to properly support them. Interviews with facility staff revealed concerns regarding proper training. While some staff reported that training is being provided regularly and they strive to meet residents’ needs, they also indicated that staffing shortages and extended work hours have impacted their ability to consistently provide quality care. A review of staff training records during the annual inspection on 04/29/2025, revealed that the facility uses an online provider to conduct annual training for their employees. However, training records were unavailable for four (4) out of eight (8) employees’ files reviewed, and one staff member had not received documented training since 2018. When LPA Conway requested training records and/or resumes for the temp agency caregivers, management were unable to provide any documentation to verify training or prior work experience. The Marketing Director and the Administrator stated they had requested the documentation form the agency, and while the agency initially indicated they would email the records, they later stopped responding to phone calls and emails. LPA Conway requested copies of any email correspondence, but these were not provided. Based on the information gathered during the course of the investigation, record review, and lack of documentation, there is sufficient evidence to determine that both facility staff and temp agency caregivers were not sufficiently trained. Therefore, the above allegation “Licensee does not ensure staff are adequately trained” 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 809-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. Continued on LIC 9099-C Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. A $250 immediate civil penalty is assessed today for repeat violation of 1569.312(a) Basic Services as licensee was previously cited on 10/14/2024. The Executive Director/Administrator, Monica Reyes, 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.