Regarding the allegation “Licensee did not comply with reporting requirements”, it was alleged that facility staff and the ED selectively report incidents to Community Care Licensing (CCL) and that serious falls and injuries are not consistently reported. Interviews with the ED revealed that the facility utilizes an internal incident reporting form completed by staff when an incident occurs. Once completed the report is submitted to the ED, who then determines whether the incident is reportable to CCL. Based on documentation and prior communication, on 4/15/2025, LPA Conway emailed the ED a reminder that incident reports must be submitted to the licensing agency, the Primary Care Physician (PCP), and the resident’s responsible party within seven (7) days of the occurrence, pursuant to Title 22 regulations. During prior visit and prior to this complaint, LPAs Conway and Dulek informed the ED that all incidents, regardless of perceived severity, must be reported to CCL. The ED acknowledged the reporting expectations and explained that while efforts are made to notify appropriate parties, the ED manages a heavy workload. However, further investigation and interviews with credible witnesses revealed that a reportable incident involving two residents, which occurred in March 2025, was not disclosed by the facility to the residents’ PCPs, hospice agencies, and/or responsible party. Instead, some of those parties became aware of the incident through contact initiated by hospital staff. Additionally, in May 2025, another resident was hospitalized, and once again, no formal notification, either verbal or written, was provided by the facility staff to the resident’s responsible party. The RP learned of the hospitalization only after being contacted directly by the hospital. Staff interviews confirmed that facility staff are not responsible for submitting incident reports directly to CCL. Instead, internal incident reports are reviewed solely by the ED, who decides whether to complete and submit a formal incident report form (LIC 624) to CCL and which are not, raising concerns about consistency and compliance in the facility’s reporting practices. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegations above are deemed SUBSTANTIATED at this time.

As to the allegation of “Staff are engaging in conduct inimical to the health and safety of residents” It was alleged that, surveillance cameras within the facility were deliberately covered with blue paper, obstructing their ability to record footage and monitor resident care. Interviews conducted with the ED confirmed that the cameras were intentionally covered with blue tape. The ED explained that this action was taken due to a former employee retaining unauthorized access to the facility’s camera system through their personal phone, even after resigning from their position. The ED stated that the decision to cover the cameras was made to protect resident confidentiality and privacy. Further, the ED reported that attempts were made to contact the former employee to disable their remote access; however, these efforts were unsuccessful. Additionally, the individual who initially installed the camera system is no longer affiliated with the facility and is unavailable to reset or reconfigure the system. Investigation determined that from early May until mid-July 2025, an unauthorized individual continued to have remote access to the facility’s surveillance camera system, accessing sensitive facility operations and compromising resident privacy and confidentiality. LPAs Conway and Dulek and IB investigators visited the facility three more times after receiving this complaint allegation and the surveillance camera system was still not operational. On 7/11/2025, the ED reported that an IT professional was hired to reset the surveillance system. The technician removed the central processing unit (“main brain”) of the system to reconfigure it off-site, with the intent to reinstall it and eliminate any unauthorized access. Today, 07/22/2025, the ED stated that the surveillance camera system password has been reset and that the system is now functioning. However, LPAs observed that surveillance cameras located in office areas, including, but not limited to, the ED’s office, the licensee’s office, the medication room, and the chart room, remained covered with blue tape. At this time, only cameras in common areas are actively recording footage. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegation above are deemed SUBSTANTIATED at this time.

Continued on LIC 909-C

A $250 civil penalty is assessed today for the citation related to CCR 87211(a)(1)(B) and a $250 civil penalty related to health and safety code 1569.58(a)(2) for repeat violations within 12 months. The Administrator Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f).

Exit interview conducted. A copy of the report and appeal rights were provided.