During today's visit LPA Mosley and ED toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. During the physical plant tour, LPA observed that the basement elevator remained closed off due to repairs previously cited during the 01/21/2026 visit. The ED informed the LPA that CCLD has been notified regarding the repair timeline. Starting at 10:30 a.m. LPA conducted six (6) in person staff interviews, starting at 11:31 a.m. conducted nine (9) in person resident interviews, conducted a record / file review and obtained copies of pertinent documents relevant to the investigation.

On the allegation, Staff did not treat resident with respect, it is the concern of the Reporting Party (RP) that staff spoke to Resident #1 (R1) in a disrespectful manner noting if they wanted their medications, they would have to get them themselves. To investigate this complaint, LPA’s conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Record review and interviews confirmed that R1 is not on a medication management program and that R1 manages their own medications. Staff do not administer or centrally store R1’s medications. R1’s physician’s report signed and dated 02/13/2025 documents that R1 is “able to administer own prescription/PRN medications” and is “able to store own medications.” R1’s assessment signed and dated 03/07/2025 documents that R1 “self-manages medications and self-manages orders/refills.”

Resident interviews revealed that they feel respected by the staff. They have no concerns with the quality of care the staff provide. They have not felt disrespected by any of the staff. They have not experienced dissatisfaction with medication distribution. Staff interviews revealed that residents are always treated with dignity and respect. They acknowledge every resident by name. If they hear that a resident has had a rough day, they check in to make sure the resident is doing well. They maintain clear boundaries and communicate appropriately, discussing resident concerns. Residents’ preferences—such as food choices, activities, interests, and likes—are consistently acknowledged and honored. Additionally, staff speak to residents with respect, upholding high standards with how they communicate. Staff have not witnessed or spoken to residents in a disrespectful manner.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not treat resident with respect” is deemed UNSUBSTANTIATED at this time. Report continued on LIC 9099-C PAGE 3...

On the allegations, Staff does not respond to call button in a timely manner and Staff unable to provide assistance in a timely manner, it is the concern of the Reporting Party (RP) that residents may be waiting up to 30 minutes to an hour for their call buttons to be addressed and for assistance to be provided. To investigate this complaint, LPA’s conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Records / file review of the facilities Pal Care system which tracks resident calls and staff response time revealed that in the time frame of the complaint, October and November of 2025. In October a total of 5,268 calls were made and in November a total of 5,421 calls were made. All calls were cleared and no calls were left uncleared. In October the average response time was 3.7 minutes and in November the average response time was 3.8 minutes.

Resident interviews indicated that staff typically respond to call buttons within 5 to 15 minutes. On rare occasions, response times may extend to 30 minutes, depending on staffing levels. Residents stated that staff always respond when a call is made and assist promptly upon arrival. No delays in response time were reported, and no concerns were noted regarding staff responsiveness or call button procedures.

Staff interviews revealed that the facility strives to respond to and clear all calls within 15 minutes, with an ideal goal of under 10 minutes. All calls are addressed promptly and consistently answered. Residents’ safety is the highest priority, and responding to call buttons is treated as an urgent matter. When staff are unable to respond immediately due to assisting other residents, they ensure communication with both team members and the residents to keep them informed. Additionally, staff provide assistance and tailor care to meet each resident’s individual needs. They make sure resident requests are addressed within the time frames specified by the residents, and all requests are fulfilled. Staff respond promptly and appropriately to specific residents’ needs. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegations of “Staff does not respond to call button in a timely manner and Staff unable to provide assistance in a timely manner” are deemed UNSUBSTANTIATED at this time.

Report continued on LIC 9099-C PAGE 4...

On the allegation, Staff does not provide safe environment for resident, it is the concern of the Reporting Party (RP) that during a fire drill staff did not check on R1. To investigate this complaint, LPA’s conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

File and record review revealed that the emergency disaster plan was reviewed on 01/15/2026.

Staff interviews revealed that the facility conducts emergency drills regularly to ensure preparedness. Residents are typically not required to participate in drills unless they choose to, but they are always informed when drills occur. Staff noted that the community maintains a safe environment and demonstrates strong emergency readiness. Care staff follow a detailed emergency guide and adhere to a structured plan. During drills or actual emergencies, staff promptly assemble, check each room, and provide assistance as needed. A binder with signage is utilized to indicate which rooms have been cleared and which require attention. After each drill, staff verify the well-being of all residents. Furthermore, the Emergency Disaster Plan is reviewed monthly to ensure it remains current and effective.

Resident interviews indicated that they feel safe within the community and currently have no concerns regarding their safety. The facility conducts drills frequently, and residents may choose to participate, though participation is never mandatory. During these drills, staff consistently check on residents to ensure their well-being. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegation of “ Staff does not provide safe environment for resident” is deemed UNSUBSTANTIATED at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was reviewed and provided.