complaint·January 26, 2026

Continued from LIC 9099 Regarding allegation “Facility does not have sufficient staffing to meet residents' needs” it was reported that due to inadequate staffing levels, residents’ needs are not consistently being met. The Marketing Director, Ashley Kumar, stated that in occasions staff call out; however, the facility utilizes a staffing agency to cover shifts when employees fail to report for duty. The representative further stated that on some occasions it is difficult to obtain coverage due to short notice from staff who do not come to work. In such instances, caregivers on duty are asked to remain beyond their scheduled shifts to provide partial coverage. Staff interviews revealed that required tasks are often not completed because although the facility schedules an adequate number of personnel, not all scheduled staff report for duty. Additionally, staff reported that caregivers provided through the staffing agency are frequently unfamiliar with the facility and residents’ needs, and in some cases are unable to perform assigned duties. AM shift staff stated that at the beginning of their shift, several residents are observed to be wet and soiled, and assistance with incontinence care has not been completed. Residents interviewed revealed ongoing concerns regarding staffing levels across all shifts. Several residents stated that it is difficult to receive timely assistance during the night shift and that staff do not check on them as frequently as needed. LPA Conway requested and reviewed facility timesheets for the month of September 2025, with specific analysis of staffing on September 18 and September 19, 2025. Review of the records revealed that during the night shift hours of approximately 2:30 AM to 6:30 AM, there were only two (2) facility staff and one (1) agency staff assigned to provide care for approximately seventy (70) residents. Additionally, review of the timesheets identified multiple scheduled caregivers who failed to report for duty during their assigned shifts. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Facility does not have sufficient staffing to meet residents' needs” has been SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation “Staff did not safeguard resident's personal belongings” it was reported that a caregiver stole money from a resident and the administrator failed to take appropriate action. An interview with the backup administrator/facility designee, Agnes Gazaryan and Marketing Director, Ashley Kumar, revealed that staff reported the allegation to management, and a meeting was conducted with Resident #1 (R1) to gather additional information regarding the incident reported. During this meeting R1 denied that any staff member stole money from them. The facility representative acknowledged that, for several days following the allegation and R1’s consent, the resident’s wallet was secured in a locked cabinet for safekeeping. The facility representative further stated that after a few days, R1 requested that their wallet be returned, and the request was honored. An interview with R1 revealed that they frequently ask facility drivers to transport them to the bank to withdraw money and often request facility staff to purchase hygiene products on their behalf. During the interview, R1 denied tipping or providing money to staff for these additional services. LPA requested receipts for the reported purchases; however, R1 was unable to provide documentation. During the interview, the resident appeared forgetful and repetitive when recounting events. Staff interviewed acknowledged purchasing some hygiene items for residents, however, they denied receiving tips of stealing money. LPA reviewed R1’s most recent Physician’s Report dated January 24, 2025. Under the mental condition section, the physician indicated that R1 is not able to manage their cash resources, with a comment stating that family manages the resident’s finances. Additionally, review of the resident Pre-Placement Appraisal Information form date January 25, 2025, signed by Administrator, Monica Reyes, indicated the resident’s mental condition as “mild forgetfulness” and the section indication assistance with managing personal cash resources was marked “yes.” LPA reviewed the facility’s operation plan and does not have a surety bond or policy or procedure in place to safeguard resident cash resources in instances where residents are unable to independently manage their finances. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Staff did not safeguard resident's personal belongings” has been SUBSTANTIATED at this time. Continued on LIC 9099-C Continued from 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 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.