Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff do not provide adequate supervision, resulting in residents falling.

It is being reported that a former resident fell and staff did not report to the resident’s family right away. On 5/19/26, LPA Shirley reviewed the staff schedule and observed that there are two staff per shift for the mornings through evenings, Monday through Friday. One staff tends to the residents and the other staff does the cooking and chores, and monitors bedbound resident or residents who sleep in. There is one staff scheduled for the nightshift as the caregiver-to-resident ratio aligns with the individual care plans and risk assessments. The night shift has a slower pace because the residents are generally asleep. Per interview with S1 on 5/19/26, the staff maintains a structured schedule which involves activities which assist with emotional wellness and helps prevent falls. On 2/25/26, LPA Felisa Shirley reviewed a letter to Community Care Licensing Department, CCLD, LPM Stephanie Cifuentes dated 2/2/26, reporting a fall by a former resident in which staff treated the resident and called the resident’s emergency contact.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not provide adequate supervision, resulting in residents falling,” therefore, the allegation is unsubstantiated.

Allegation: Staff did not communicate with residents authorized representative.

It is being reported that R1 fell out of the bed several times and these incidents were never reported to the resident’s emergency contact person. On 2/25/26, LPA Shirley requested the incident reports for the prior 6 months. LPA Shirley reviewed incident reports requested, however, there were no reports for R1 falling. Per interview with S1, staff monitors the rooms for bedbound resident or residents who are in bed.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident was not aware of the situation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not communicate with residents authorized representative,” therefore, the allegation is unsubstantiated.