complaint·October 24, 2025

Continued on LIC 9099-C Regarding allegation of “Staff do not speak appropriately to residents in care” the RP expressed concern that staff demonstrate poor communication practices, including making inappropriate remarks such as telling residents to leave the facility if they are dissatisfied. Interviews conducted with residents and family members revealed mixed responses. Some residents and family members reported that there is a language barrier between staff and residents and that on certain occasions, staff members have used an unfriendly or dismissive tone when interacting with residents. Other residents denied experiencing any inappropriate behavior or communication issues with the staff. Interviews with staff denied the allegation and expressed that, at times, some residents can be verbally abusive or rude toward staff, which may lead to challenging interactions. The administrator stated that staff are continuously reminded to maintain professionalism when interacting with residents. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff do not speak appropriately to residents in care” is deemed unsubstantiated at this time. Exit interview conducted and a copy of this report was provided. Continued from LIC 9099 Regarding allegation “Licensee does not ensure enough staff are present to meet the needs of residents,” the Reporting Party (RP) expressed concern that the facility was short-staffed on Easter night (4/20), and the night of Saturday 5/10/25. Interviews with the Licensee and the ED confirmed that the facility has experienced staffing challenges. However, the ED stated that the facility maintains sufficient staffing levels to cover for employees who resign or call out due to illness using caregiver from a staff agency. LPA requested and reviewed facility timecards and staffing records, including any documentation of agency staff used to provide coverage during the specified dates. Per ED, agency personnel were not called in to cover staff call-outs on those days. LPA Conway conducted a comprehensive review of the facility’s timecards, which revealed that on 4/20/2025, five (5) scheduled staff members did not report to work, and on 5/10/2025, six (6) scheduled staff members did not report to work. Additionally, it was observed that some staff took their lunch breaks simultaneously rather than staggering their breaks which resulted in temporary service interruption and reduced supervision of residents. Staff reported feeling overworked and stressed due to persistent staffing shortages. They indicated that they are frequently required to assume additional responsibilities and take on extra shifts. Staff reported that this level of understaffing has led to them rushing through tasks leading to careless, delays in assisting residents, and longer response times to resident call signals. Interviews with residents revealed that occasionally staffing levels are insufficient to meet care needs of residents. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “ Licensee does not ensure enough staff are present to meet the needs of residents, has been SUBSTANTIATED at this time. Continued from LIC 9099-C Continued from LIC 9099-C Regarding allegation “Staff do not provide adequate food service to residents” the RP expressed concern that there are often not enough staff available to feed residents in the Memory Care (MC) unit. Interviews conducted with the administrator revealed that the facility has experienced staff challenges due to staff call-outs, which have occasionally affected daily operations. However, the administrator denied that residents in the MC unit have ever missed meals or gone unfed. A review of group text messages among staff indicated that residents in the MC unit have complained of hunger on two (2) consecutive days due to not being served dinner. Interviews conducted with credible witnesses including staff, residents, and family members, revealed consistent concerns that residents are not receiving sufficient meals or snacks. Family members also reported taking upon themselves to bring additional food and snacks during their visits to ensure residents have enough to eat. Other residents also reported dissatisfaction with both the quantity and quality of the food. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff do not provide adequate food service to residents” has been SUBSTANTIATED at this time. A $250 civil penalty is assessed for the citation related to CCR 87411(a) for a repeat violation. Facility designees, Agnes Gazaryan and Ashley Kumar were informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). 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.