Allegation: Staff do not provide adequate supervision, resulting in residents falling.

It is being reported that a former resident fell and staff did not report to the resident’s family right away. On 5/19/26, LPA Shirley reviewed the staff schedule and observed that there are two staff per shift for the mornings through evenings, Monday through Friday. One staff tends to the residents and the other staff does the cooking and chores, and monitors bedbound resident or residents who sleep in. There is one staff scheduled for the nightshift as the caregiver-to-resident ratio aligns with the individual care plans and risk assessments. The night shift has a slower pace because the residents are generally asleep. Per interview with S1 on 5/19/26, the staff maintains a structured schedule which involves activities which assist with emotional wellness and helps prevent falls. On 2/25/26, LPA Felisa Shirley reviewed a letter to Community Care Licensing Department, CCLD, LPM Stephanie Cifuentes dated 2/2/26, reporting a fall by a former resident in which staff treated the resident and called the resident’s emergency contact.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not provide adequate supervision, resulting in residents falling,” therefore, the allegation is unsubstantiated.

Allegation: Staff did not communicate with residents authorized representative.

It is being reported that R1 fell out of the bed several times and these incidents were never reported to the resident’s emergency contact person. On 2/25/26, LPA Shirley requested the incident reports for the prior 6 months. LPA Shirley reviewed incident reports requested, however, there were no reports for R1 falling. Per interview with S1, staff monitors the rooms for bedbound resident or residents who are in bed.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident was not aware of the situation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not communicate with residents authorized representative,” therefore, the allegation is unsubstantiated.

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It is being reported that R1 called a family member to report that he needed assistance in the facility and the staff weren’t responding when he pressed the call bell. Per interview with S1 on 5/19/26, when call bells are heard by the staff, there is an immediate response if the staff is not assisting another resident. On 5/19/26, LPA Shirley had S1 trigger the call button while I went to the kitchen to assess the alert volume. LPA Shirley did not hear an alert, as the system was unplugged. The system was unplugged today, but I can’t confirm if it was unplugged at the time of the residents’ request or initial investigation. Per interview on 2/25/26 with R4, staff responds to their call after they are done assisting another resident. R4 stated that she understands she is not the only one. 2/25/26, S3 stated if the direct call lines to the facility go unanswered, families sometimes utilize the personal contact numbers of the staff, and staff answers or return calls at their earliest convenience.

LPA interviewed staff 1 – staff 3(S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two Residents confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not respond to residents call bells in a timely manner,” therefore, the allegation is unsubstantiated.

Allegation: Staff do not answer phone calls in a timely manner.

It is being reported that calls go unanswered to the facility during the evening hours despite numerous attempts. During the interview with the Administrator, 2/25/26, she indicated that staff promptly handles all incoming calls. Per interview, 2/25/26, S3 stated if the direct lines to the facility go unanswered, families sometimes utilize personal contact numbers of the staff, and staff return calls at their earliest convenience. Per S3, if they are working with a client, they can’t return calls until they are done with the client.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two neither confirmed nor denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not answer phone calls in a timely manner,” therefore, the allegation is unsubstantiated.

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It is being reported that a resident needed assistance in the facility and the staff weren’t responding when he pressed the call bell. Per interview, 2/25/26, S3 stated that once he’s completed working with the current resident, he checks in with the other residents to offer support. Per interview, 2/25/26, R4 stated at times the staff informs her they are working with other residents. R4 states that she knows she’s not the only one that needs assistance, but she doesn’t wait too long.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not ensuring to meet the residents’ needs in a timely manner,” therefore, the allegation is unsubstantiated.

Allegation: Staff speak inappropriately to residents in care.

It is being reported that staff are using disrespectful and inappropriate language to the residents. Based on interviews on 2/25/26, with staff and residents, there is no evidence of inappropriate verbal communication. Based on review of requested incident reports, there is no report of staff speaking inappropriate to residents.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff speak inappropriately to residents in care,” therefore, the allegation is unsubstantiated.

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It is being reported that the staff does not provide residents with activities and keeps them in their rooms for most of the day. During each of my unannounced visits as a Licensing Program Analyst, I have observed residents spending their time in the main living area. Today, 3/4/26, when LPA Shirley arrived to this facility, I observed and heard R4 and her visitor singing a gospel song being sung on the music channel that they were watching. LPA Shirley observed, R3 engaged on her phone enjoying mobile gaming. On 2/25/26, LPA Shirley observed videos and pictures of the residents doing chair exercises, pedaling and walking in the backyard. Per interview with R4, 2/25/26, she doesn’t participate in the exercises anymore as she has grown tired of doing them. Per observation on 5/19/26, LPA Shirley observed R4 doing chair exercises by herself with a pleasant look on her face.

LPA interviewed staff 1 – staff 3(S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that residents are provided with activities,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Renette DeLaCruz.