Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not seek timely medical attention

It is being alleged that facility staff failed to contact emergency services for a resident in care.

On 09/19/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that documentation reflected staff recognized the change in the resident’s condition and called 911 for medical attention. A1's expectation of the staff is to respond appropriately and take immediate action when a resident exhibits serious symptoms. A1 indicated that staff are expected to notify a Certified MedTech and/or a Licensed Nurse immediately, and 911 should be called as needed.

On 09/10/2025 and 10/13/2025, LPA conducted interviews with Staff (S1- S4) regarding the allegation above. 1 out of 4 staff interviewed confirmed the allegation above and reported witnessing the incident in question with Resident 13 (R13), per 1 of 4 staff protocol was followed and 911 was called. 1 out of 4 staff interviewed reported being aware of the incident but did not witness it. 2 out of 4 staff interviewed denied the allegation and stated not having knowledge nor witness any emergency regarding the Resident 13 (R13).

On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12), regarding the allegation above. 1 of 12 residents confirmed the allegation and stated that on the day of 09/10/2025 and a week from 09/10/2025 their neighboring resident had to wait a long time before getting help from the facility staff. 11 of the 12 residents reported having no knowledge of the allegation above.

On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. On 10/17/25 LPA reviewed the staff schedule (dated on 09/05/2025), and observed the following: during the AM shift two (2) caregivers in Units 1 and Unit 4, three (3) caregivers in Unit 2, one (1) caregiver in Units 3 and Unit 5. During the PM shift in Unit 1, Unit 3 , and Unit 5 - two (2) caregiver each were scheduled to work. In Unit 4 - one (1) caregiver is scheduled to work.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).