Complaint Investigation Report

LPAs observed that the facility conducted an emergency disaster drill in the second quarter of 2026, however, the facility only conducted the training with the overnight staff. The facility did not conduct the training with the morning or afternoon shift staff as required per regulations. The Department conducted five staff interviews. Three staff interviewed confirmed that they did not participate in an emergency disaster drill in the second quarter of 2026.

Regarding the allegation, facility is not following their emergency disaster plan, the following has been concluded: During the investigation, the Department reviewed the facility's emergency disaster plan. Per the facility's emergency disaster plan on page six, it states" If there is a need for more power the facility is prepared to rent an additional generator from Home Depot. It states that if the emergency call system becomes inoperable, staff will implement a manual check-in and visual monitoring. It further states that caregivers will perform request safety rounds 15-30 minutes or as needed. Lastly, it states that during power outages or emergencies, battery operated and back-up oxygen tanks will be made available for residents using concentrators." The Department conducted five staff interviews. Five out of the five staff interviewed confirmed that the facility did not rent a generator from Home Depot as stated in their emergency disaster plan. Three staff interviewed confirmed that facility was also unable to complete safety rounds every 15-30 minutes as stated in their emergency disaster plan due to lack of staffing. Staff interviewed also confirmed that the facility did not have back-up oxygen tanks available for the four residents of the facility that require oxygen. The staff interviewed reported that the four residents went without oxygen and were just monitored during the approximate nine hour power outage. The Department conducted eight resident interviews. Eight out of the eight resident interviewed also corroborated the allegation. The eight resident confirmed that the facility did not have a generator present during the power outage. The eight residents confirmed that staff did not complete safety rounds every 15-30 minutes. The residents interviewed reported that staff only checked on them one or twice during the entire power outage which lasted approximately nine hours.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the four allegations listed above. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D pages. An exit interview was conducted with Executive Director Lauren Chon. A copy of the report and appeal rights were provided at time of visit.