Complaint Investigation Report

Based on interviews and observations, the preponderance of evidence showed that the pull chords in 4 out of 5 bathrooms tested did not transmit signals to the staff pager. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).

A Plan of Correction was jointly developed with the Executive Director. The ED, who represents the new management team who took over on July 9, 2025, immediately purchased a new call button system that will replace the pull chords and will be installed immediately. The ED provided proof during the complaint visit that the system was purchased.

**NOTE: LPA Silveira left the facility for a one (1) hour lunch break and returned to complete the investigation.

An exit interview was conducted with Megan to whom a copy of this report, the LIC 9099 D page and the Licensee/Appeal Rights (LIC9058 01/16) were provided.