complaint·October 24, 2025

Continued from LIC 9099 Regarding allegation “Facility staff are not providing incontinence care as needed” it was reported that during the nocturnal (NOC) hours, staff are not checking on residents regularly, leaving them soiled for extended periods of time. An interview with the Marketing Director revealed that night and NOC staff have been reporting to work as scheduled and they have not received formal complaints from residents regarding un-met incontinence needs. Interviews with the morning (AM) staff indicated that residents are often found soiled at the beginning of their shift and have expressed frustration about waiting for long periods before receiving assistance after activating the call light system. NOC staff denied the allegation, stating that all required checks and incontinence care are being provided as scheduled. Resident interviews, however, revealed consistent concerns regarding staffing levels during all shifts. Several residents stated that it is difficult to receive timely assistance at night and that staff do not check on them as frequently as needed. Some residents reported feeling neglected and described instances where staff where “nowhere to be found” when they were wet and soiled and assistance with incontinence care was required. One resident in particular, Resident #1, reported activating the call cord for restroom assistance and waiting approximately 40 minutes without receiving help. Eventually attempted to get up independently, lost balance, and sustained a fall that required hospitalization. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Facility staff are not providing incontinence care as needed” has been SUBSTANTIATED at this time. Regarding allegation “Staff sleep while on duty” it was the reporting party’s concern that Nocturnal (NOC) staff sleep throughout their shift, resulting in residents not being monitored, rounds not being conducted, and residents not receiving assistance during the nighttime hours. NOC staff denied the allegation, stating that required rounds and resident checks are being conducted as scheduled. Interviews with residents revealed that it is difficult to receive timely assistance at night and that staff do not check on them as frequently as needed. Some residents reported feeling unattended and that staff are frequently not present or available when assistance was required. Continued on LIC 9099-C Continued from LIC 9099-C An interview with the back-up administrator indicated that on the night of 09/28/2025, security camera footage was reviewed at approximately 3:00 AM and it appeared that Staff #1 (S1) was covered with a blanket and asleep on the couch located in the main entrance area. S1 was released from their duties on 09/29/2025. During the interview, S1 denied being asleep but stated that they were not feeling well that night and chose to come to work instead of calling out sick. S1 further stated that after conducting resident checks, they decided to rest briefly before completing the next round of checks. Additional staff interviews confirmed that some staff members have observed or heard that NOC staff occasionally sleep in the library during their shift, leaving residents unattended for extended periods. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff sleep while on duty” has been SUBSTANTIATED at this time. Regarding allegation “Staff does not respond to residents’ calls for assistance in a timely manner” it was reported that staff fail to respond promptly when residents request help. During a physical plant tour conducted with the back-up administrator on 09/26/2025, LPA tested the functionality of the call light system. After confirming that all prior calls had been cleared from the switchboard, LPA activated the call cord in room #522 and observed that multiple room indicator lights, including those in rooms where no assistance was needed, illuminated on the system board located at the main entrance. The back-up administrator explained that the facility’s call light system is outdated and not function as intended. Marketing Director explained that staff are able to identify which room is calling for assistance because, even though multiple rooms light up, the light corresponding to the room calling for assistance illuminates brighter on the switchboard. Interviews with staff stated that some hallway signal lights, which are designed to activate when a resident pulls the call cord, were burnt and not operational. As a result, staff are sometimes unable to identify which residents require assistance unless the resident verbally calls out to staff passing by. Interviews with residents revealed consistent concerns regarding delayed response times across all three (3) shifts after pulling the call cord before receiving assistance. Several residents also expressed concerns that having only two (2) caregivers on duty is not sufficient to meet the needs of the entire assisted living unit. Additionally, some residents alleged that staff intentionally place call cords out of reach so staff are not disturbed during the night. Continued on LIC 9099-C Continued from LIC 9099-C During different visits to the facility, LPA observed shared resident rooms in which the call cord system was located in the middle of the room between who (2) resident beds, with only one (1) cord available for both residents. LPA also observed that in some rooms, the call system consisted of a fixed wall switch rather than a traditional muti-directional pull cord. When LPA tested some of these switches, they did not engage properly, preventing activation of the call light system. LPA asked Resident #2 (R2) how they request assistance when the call cord does not engage. R2 stated that when assistance is needed, they verbally call out to staff members passing by in the hallway since the call cord system in their room is not functioning properly. R2 added that this is very difficult and often takes a long time, as it can be some time before a staff member is seen walking through the hallway. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff sleep while on duty” has been SUBSTANTIATED at this time. A $250 civil penalty is assessed for the citation related to CCR 87464(f)(1) for a repeat violation. The back-up administrator, Agnes Gazaryan and Marketing Director, 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.