Complaint Investigation Report

Regarding the allegation of Facility is not reporting falls and other incidents involving residents revealed the following: 3 of 4 staff informed LPA that they report incidents to the Administrator. 1 of 4 staff informed LPA that they will write the reports and give them to the Administrator to submit them to licensing. 1 of 4 staff informed LPA that they had the incident reports but did not submit them to licensing.

Upon records reviewed it was revealed that incident reports were written for Resident #1 (R1) that were not submitted to the Regional Office of Orange County.

Regarding the facility allegation of Resident fell and sustained injuries due to a lack of supervision revealed the following: Records reviewed revealed a physicians report for R1 dated October 15, 2025, stating that R1 needs assistance with repositioning and transferring, is not able to dress, bathe or care for their own toileting needs. R1 was marked as non ambulatory due to their physical condition and unable to independently transfer to and from bed. This report was signed by a medical professional. LPA observed a needs and services plan dated January 22, 2026, stating that R1 has upper and lower extremity weakness and requires assistance with transfers and mobility. R1 was noted with poor safety awareness with attempts to get out of bed unassisted and has a history of falls. The needs and services plan states that R1 requires assistance with transfers and mobility and is often non-compliant. The plan also states that staff will assist R1 with their daily activities. LPA observed a staff schedule for the week of December 8, 2025, through December 14, 2025, that indicated 2-3 caregivers are on duty for the morning shift, 2 caregivers and a medtech for the evening shift and one caregiver and one medtech for the night shift. This schedule did not indicate any call offs for LPA to review.

Interviews with staff revealed 4 of 4 staff informed LPA that there are normally 2 caregivers and a medtech on duty. 1 of 4 staff informed LPA that there is not enough staff to assist with resident needs. 1 of 4 staff informed LPA that they meet residents needs due to not having a choice regardless of staffing. 2 of 4 staff informed LPA that staff meet all residents needs. 1 of 4 staff informed LPA that the facility has staffing issues due to call offs. 1 of 4 staff informed LPA that they will take on caregiver duties to ensure resident needs are being met. 4 of 4 staff informed LPA that the facility does not have a housekeeper or a cook and caregivers do house keeping duties on top of their care giving duties.

Interviews with residents revealed 2 of 4 residents informed LPA that there is a lack of staffing at the facility and it looks like the caregivers could use assistance. 1 of 4 residents informed LPA that they are independent and do not need much assistance. 2 of 4 residents informed LPA that their needs are met by staff.