Complaint Investigation Report

The allegation of “Staff do not respond in a timely manner to assist resident.” alleges that, facility staff do not respond to resident’s requests for assistance in a timely manner. LPA interviewed facility residents who expressed concerns in the amount of time it takes facility staff to respond to resident’s requests for assistance. Resident #1 (R1) stated that staff take anywhere between twenty (20) minutes to two (2) hours to respond to their requests for assistance. Resident #2 (R2) stated that they had been left in soiled diapers overnight on multiple occasions due to staff not assisting residents at night. Resident #3 (R3) was unable to provide an estimated time on how long it takes staff to assist them but reported that facility staff eventually assist them with their needs but R3 believed that staff could be faster about providing care to them. LPA interviewed two (2) facility caregivers. The caregivers interviewed stated that they respond to resident’s requests for assistance as soon as they are asked. Staff stated that their shifts end at 06:00 PM on the days they work and that the facility Administrator provides care to the residents during the night until shift start at 06:00 AM. The facility staff members stated that they do not remain at the facility after their shift ends. One (1) staff member interviewed confirmed that in the past at the start of their shift (06:00 AM) they had observed facility residents in diapers that were soiled during the night and not changed. LPA interviewed the Administrator who stated that they remain awake until 12:00 AM and that they perform checks on the residents during the night. The Administrator stated that staff are expected to check on the residents throughout the day. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Staff do not respond in a timely manner to assist resident” Therefore, the allegation is deemed Substantiated at this time.

LPA reminded the Administrator that the facility is responsible for providing basic services including appropriate care and supervision to the residents in care. The Administrator expressed understanding and agreed to conduct training with all current staff members to discuss the importance of periodic checks on the residents to ask if they need assistance. Administrator agreed to send Community Care Licensing Division (CCLD) their plan on how they would ensure adequate night supervision for residents between 06:00 PM and 06:00 AM. LPA informed the Administrator that they were recently cited for a violation of California Code of Regulations (CCR) 87464(f)(1) on 03/30/2026. LPA informed the Administrator that because they violated the same licensing regulation within a twelve (12) month period a civil penalty in the amount of $250 is being assessed on today’s date (06/03/2026).

The following deficiency was cited and civil penalty assessed (Refer to LIC 9099D). Exit interview was conducted, a copy of the report was printed, and appeal rights were provided.