Complaint Investigation Report

On 03/02/2026, the LPA interviewed the Administrator, Assistant Administrator, conducted one phone interview with Witness 1 (W1), and obtained copies of resident records and other pertinent documents relevant to the investigation. On 03/11/2026, the LPA interviewed the Assistant Administrator, two (2) staff, conducted a resident file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 03/12/2026, LPA conducted a phone interview with a hospice nurse.

On the allegation, “Staff are not properly trained” it is the concern of the reporting party (RP) that caregivers appeared inexperienced and insufficiently trained. It was further reported caregivers are not trained on how to contact hospice if needed. To investigate the complaint, the LPA conducted a file review and interviews. File review revealed that two (2) out of two (2) caregivers were missing nine (9) out of ten (10) hours of initial medication training. Interview with the administrator revealed that all of the staff training was in the files and a copy of the staff training was given to the LPA. Based on staff interviews and file review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time.

The following deficiency was cited from the CA Code of Regulations, Title 22 (refer to LIC 9099-D). A copy of the report and appeal rights will be emailed/mailed to the former Licensee.