Complaint Investigation Report
On the allegation " Facility is in disrepair" on 8/27/2025 LPA inspected a random selection of residents rooms. LPA observed that residents personal pendents are having issues notifying staff when pressed and ED as well as the HSD confirmed that there is a dead zone for rooms 201-204 as well as rooms 243 and 241 which they were actively trying to get resolved. At the time of the visit the pendents were not working and were in disrepair therefore the allegation Facility is in disrepair is substantiated.
On the allegation "Facility is not adequately staffed" LPA conducted interviews on 3/20/2024 with residents as well as reviewed staffing available for the month of August 2025. LPA interviewed R1, R2, and R3. All residents stated that they feel that there is not enough staffing and that they have had trouble with getting assistance in a timely manner as a result. R1 stated that the facility has had issues with staffing and high turnover. R2 stated that they notice staffing is short especially on the weekends and that they have been told that they will have to wait longer due to the shortage. R2 also stated that there are sometimes only 2 staff for all of assisted living (AL) R3 stated that when they press their pendant to get assistance it can take a really long time due to the shortage of staff. LPA observed that on 8/24/2025 there was only 1 caregiver and 1 medtech available in AL from 6am- 2pm. Originally 2 caregivers were scheduled however 1 called out. On 8/24/2025 the census was 56 in AL and 31 in memory care (MC). Memory care typically has at least 5 caregivers on shift. Therefore the allegation "Facility is not adequately staffed" is substantiated.
Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview conducted with Executive Director, San Sor. Appeal rights and copy of this report provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction