Complaint·April 29, 2026

Continued from 9099.... The complaint alleges that “Staff does not ensure incident reports are being reported ”. The complainant states that the Staff are not appropriately reporting incidents. Complainant states that staff (S1) is willingly reading and disposing of Incident Reports constructed by care staff. LPA reviewed incident reports submitted and found that through October and November of 2025 there were 7 incident reports submitted; 5 were death reports, 1 was a resident requiring medical treatment and 1 was for a fall. LPA spoke with 8 staff members: 8 of 8 staff members stated that they do not believe staff/med techs/Administrator are ignoring their reporting of incidents nor is the Administrator disposing of incident reports that staff are submitting. Based on the interviews conducted and review of Incident Reports submitted the allegation that staff does not ensure incident reports are being reported is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated . The complaint alleges “Staff does not ensure facility operates in ratio” . The facility staff schedule shows coverage in Assisted Living, Memory Care and Hospice units. LPA also discussed staffing with Administrator who stated that call-offs are covered by Administrator and/or Directors to ensure adequate coverage. A review of staff schedules shows that there are 2 to 3 care staff and one med technician scheduled in memory care per shift, 1 care giver for the hospice wing per shift and 2 to 3 care staff for the Assisted Living with the med technician depending on the shift. This facility is licensed as a Residential Care Facility for the Elderly (RCFE) and Title 22 Regulations does not require any staffing ratio. Regulations for RCFE’s state that staff provides adequate care and supervision. The complainant stated that California Code of Regulations (22 CCR)§ 87865.1 (for residential care facilities for the chronically ill) requires ratios, however this facility is not a residential care facility for the chronically ill and therefore this regulation does not apply. The allegation that “Staff does not ensure facility operates in ratio” is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence . The Complaint alleges that “Staff mismanages residents' medications”. The complainant states that med techs are not properly utilizing hand over hand method when administering medications; as well as not administering medications in a timely manner." LPA conducted interviews with 4 med techs and asked them to explain the hand-over-hand technique. 4 of 4 med technicians were able to demonstrate the correct method. LPA also asked them to explain what they would do if the resident was unable to participate in the hand over hand method and 4 of 4 responded that they would call hospice to administer the medications because they are only allowed to assist. The complainant also stated that medications were not administered in a timely manner. A review of the Medication Administration Records (MARs) indicate that medications were administered as per doctors’ orders. Based on interviews with staff and review of medication administration records the allegation that “Staff mismanaged residents’ medications” is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.