Complaint Investigation Report

This report supersedes the report created 9/23/25 and the findings will remain unchanged.

Allegation: Facility does not have sufficient staffing to provide care to residents.

The details of the complaint alleged that it was observed that there are not enough staff during regular hours.

On October 21, 2025, at 1:00 p.m., Licensing Program Analyst (LPA) Iniguez reviewed the facility’s Call-off Tracking Log for September 29–30 and October 1–3, 2025. The log showed that the facility typically schedules 30 care staff per day, with a maximum of 5 callouts per day, resulting in 25 staff available for care and supervision. On December 22, 2025, at 10:00 a.m., LPA Iniguez also reviewed Functional Capabilities Assessments (LIC 9172) for 56 residents, aged 67 to 97, whose care needs range from independent to requiring extensive assistance. The daily staffing schedule includes 9 caregivers, 3 medication technicians, and 1 LVN during the AM shift (13 staff); 8 caregivers, 3 medication technicians, and 1 LVN during the PM shift (12 staff); and 7 caregivers with 1 medication technician during the NOC shift (8 staff). This totals 24 caregivers, 7 medication technicians, and 2 LVNs, for a total of 33 staff per day. Based on this review, the facility maintains adequate staffing to meet the care and supervision needs of all 56 residents, even on days with the highest callouts. With approximately 25 care staff for 56 residents, the staff-to-resident ratio of about 1:2.2 exceeds minimum standards and is appropriate for a population with mixed acuity, provided staff are properly trained, and tasks are well organized.