Complaint Investigation Report

R1 moved into the facility on November 18, 2023. On October 22, 2025, R1’s responsible party began staying with R1 at the facility after a medical procedure. R1’s responsible party reported that they heard an alarm go off in R1’s room frequently without staff responding to the alarm. All resident rooms at the facility have smoke detectors/carbon monoxide detectors. R1’s responsible party reported that staff did not come to the room to investigate the cause but assured her the room was safe. R1 reported that they had heard the alarm go off in their room on a few occasions and called the front desk, which resulted in the alarm being silenced but no one coming to the room to check on anything. R1’s responsible party purchased two portable Carbon monoxide (CO) detectors as a precaution. On November 19, 2025, the two portable CO detectors began to alarm and R1’s responsible party called 911. Orange County Fire Authority responded and found R1’s room had no measurable CO. Facility staff ordered a technician to find the cause of the CO and the fire department advised not to re-enter the room until a professional technician advised it was safe. No cause for the CO alarm was found, and no action was taken at that time. On November 23, 2025, CO detectors began to alarm, and the room alarm went off. R1’s responsible party called 911. The Orange County Fire Authority responded to the call. A review of the incident report from Orange County Fire Authority shows CO was detected in R1’s room with readings from 8 to 220 parts per million (ppm). The California Department of Industrial Relations (DIR) and Cal/OSHA enforce a Permissible Exposure Limit (PEL) for carbon monoxide (CO) of 50 parts per million (ppm) as an 8-hour time-weighted average (TWA) in any enclosed space. First responders stayed at the facility until readings went to zero. R1 and their responsible party had already vacated the room when the alarms went off. During the incident the Facilities Director reported that they would shut down the pool pump which may have been causing the CO issue. A review of records for the fire safety alarm system show that gas (CO) was detected 53 times from November 6, 2025, to November 19, 2025. The Facilities Director reported that when the first alarm went off on November 6, 2025, they assumed the CO sensor was faulty and had the sensor replaced on November 8, 2025. The Facilities Director was unable to explain why they failed to further investigate the cause of the CO alarm to continue to go off or to take further action to prevent possible life-threatening injury from CO exposure. 2 of 2 staff interviewed who had worked at the front desk reported that when the alarm company called about R1’s room alarm going off because of gas, they were instructed to tell them it was because of a faulty sensor. Both staff members verified that the alarm company called on multiple occasions to report to the facility that the gas alarm in R1’s room was going off. The Administrator reported that the Facilities Director oversaw the alarm system and was unaware that the CO alarm had been sounding regularly after the CO sensor was replaced.