On 04/17/2026 LPA Chiarelli arrived at the facility unannounced and toured the facility. LPA Chiarelli and administrator Michael Lang toured house 1 and R1 (resident one) room. LPA Chiarelli observed that R1 had a bed alarm attached to his bed. Administrator Lang showed LPA Chiarelli how the bed alarm worked and that it was functioning properly. LPA Chiarelli reviewed R1 file and it showed that hospice documented that they placed a bed alarm on R1 bed because they were determined to be a fall risk. LPA Chiarelli did not have evidence to prove that staff were not meeting the plan for care and determine if staff had removed the bed alarm for an extended period of time or not.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.

During the investigation LPA Chiarelli and LPA Adkison completed a medication audit and residents medications were reviewed. While medications were being reviewed it was observed that resident one R1 had two medications that had missing doses. The first medication observed for R1 was prescribed by the doctor to be taken twice daily but there were twelve (12) missing doses of the medication that were unaccounted for. In the E-MAR that the facility uses there were no notes on why the medication was unaccounted for.

Allegation - Residents toileting needs are not being met timely due to insufficient staffing. – substantiated

During the investigation several staff members were interviewed and records were reviewed. LPA Chiarelli interviewed a staff member that they stated that “Yes, for the past several months I have been working by myself. There usually is a med tech but they float between houses 1 and 2 and when they are at house 2, I am left alone. Most of my shifts I am the only caregiver.”

LPA Chiarelli asked - Do you have any residents that need two staff to transfer them?

S1 – Yes, we do. We only have a few but one of them we got a hoyer lift for, but it can be difficult to get them out of bed on my own or because we do not have enough staff we cannot lift them out of bed. We also have a resident that primarily uses a commode but if I do not have another caregiver to help me I just change their diaper, because I need a second caregiver to help me transfer them to the commode. Usually during my shift I can get my checks and diaper/depends changed completed. But for other shifts it can be difficult to get it all done.

LPA Chiarelli – Do you have ever have a shortage of diapers/wipes and another incontinence items?

S1 – Yes, we do. If we cannot find diapers or incontinence items, we do take them from other residents because we cannot leave residents wet or in a dirty diaper.

LPA Chiarelli interviewed another staff member (S2) who worked a different shift and stated “Here is a brief from a resident that wasn't changed for three days after our AM shift ended, she had the brief on until 3/27-3/30. I think this was due to the shortage of staff. She isn't the only resident we found with the same brief on.” (Photo evidence was provided).

Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.