complaint·December 11, 2025

Continued on LIC 9099 Regarding allegation “Facility does not have adequate emergency plans to meet the needs of all residents” the Reporting Party (RP) expressed concern that Memory Care (MC) residents are locked in their rooms unable to exit in the event of an emergency. Interviews conducted with staff revealed that residents are able to exit their rooms freely, as the doors are not locked from the inside. Facility representatives explained that in the MC unit, resident doors are equipped with storeroom locks which can lock from the outside but remain unlocked from the inside at all times. This measure was implemented due to incidents involving wandering residents attempting to enter other residents’ rooms, as well as residents forgetting which room belongs to them and attempting to open multiple doors. LPA observed a few residents wandering within the MC unit who attempted to open various doors. Also, LPA inspected eight (8) random resident rooms and confirmed that all locks lock from the outside but remain unlocked from the inside at all times. With regard to the allegation that the facility lacks an adequate emergency plan, facility representatives stated that all staff receive training and are assigned responsibilities and specific roles to ensure the safe evacuation and accounting of all residents during an emergency. The facility conducts emergency disaster drills and maintains an up-to-date Emergency Disaster Plan. LPA reviewed the most recent drill documentation and the updated Emergency Disaster Plan and found the facility to be in compliance with applicable regulations. Based on the information obtained during the investigation, the Department 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 above allegation “Facility does not have adequate emergency plans to meet the needs of all residents” is deemed UNSUBSTANTIATED at this time. No deficiency related to the allegations were cited. Exit interview conducted. A copy of the report was reviewed and provided. Continued from LIC 9099 Regarding the allegations of “Licensee did not ensure that oxygen tanks were properly stored” and “Licensee do not ensure staff are sufficiently trained”, the Reporting Party (RP) expressed concern on how oxygen tanks are being stored inside resident’s rooms and indicated that the improper storage suggest staff may not be adequately trained. Interviews with staff, including housekeeping personnel, revealed that they could not recall the last time they received training on the proper storage of oxygen tanks. During the interviews, a housekeeper stated that staff responsible of cleaning and tidying residents' rooms often place the oxygen tanks on top of the concentrators while performing their duties. A facility representative further stated that staff training had not been provided on how to properly handle and store oxygen since beginning their employment several months ago. LPA requested documentation of the most recent staff training on proper oxygen handling and storage. The facility presented training conducted on 03/2024 where eight (8) Med-Techs attended this training; however, six (6) of them are not longer employed at the facility. Additionally, caregivers and housekeeping staff were not included in the training. During the visit, LPA entered rooms where oxygen was being used and observed unsecured oxygen tanks lying on their side on top of an oxygen machine and/or standing on the floor next to an oxygen machine. Based on the information gathered during the investigation, the department has sufficient evidence to confirm these allegations occurred. Therefore, the allegations of “Licensee did not ensure that oxygen tanks were properly stored” and “Licensee do not ensure staff are sufficiently trained” have been 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.