Complaint Investigation Report

Allegation: Staff are not adequately trained.

It was alleged that there are many staff members who are not trained.

On 11/13/2025, between the hours of 11:12am - 11:22am, LPA interviewed A1, who denied the allegation and stated that in-service training for staff is conducted once a month, and this month's training will address fall risk.

Between 9:15am - 1:21pm, LPA interviewed 9 staff members: 9 of 9 staff denied the allegation and stated they receive in-service training on a regular basis.

Between 8:20am - 2:00 pm, LPA interviewed 10 residents: 8 of 10 residents denied the allegation and stated the staff know what they are doing when helping residents and have not noticed a difference between newer staff and those who currently work or formerly worked at the facility. 2 of 10 residents did not confirm nor deny the allegation; R6 stated "no comment," while R8 stated doesn't think much about it because they don't know which staff are new and that does not involve himself.

On 12/16/2025, between 8:35am - 11:15am, LPA conducted a records review and observed the following: For 2025, the facility conducted twenty-nine (29) in-service training's between January 28, 2025, - September 29, 2025. Each training included a sign-in sheet acknowledging staff participation and understanding of the material presented. Topics covered during these trainings included new employee orientation; sexual harassment; workplace violence; injury and illness prevention; bloodborne pathogens; missing resident response procedures; dementia and memory care practices; activities of daily living and personal care; medication administration; infection control; residents' rights and mandated reporting; fall and elopement safety; housekeeping and food safety practices; activity programming; customer service; and applicable facility policies and procedures.

A total of 46 employees work for the facility, with 18 out of 46 staff members being caregivers.

Of the 18 caregivers out of the 46 staff have not completed all the required training per Title 22 regulations and health & safety code.

Based on LPA's observations and interviews that were conducted and the records that were reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6, Chapter 8, as cited on the attached LIC 9099D.

Exit interview conducted with Catherine Dacara (Administrator) and a copy of this report with appeal right was provided.