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32 | Allegation: Facility does not have sufficient staff to provide care and supervision to residents
It was alleged the facility is operating without enough staff to properly care for residents in care.
Five (5) of five (5) staff members interviewed agreed that the facility was understaffed and staff were unable to care for residents properly because of this. Two (2) of two (2) residents interviewed agreed that the facility had been regularly understaffed to meet their needs. One resident, R1, claimed they had waited for approximately two hours for staff assistance to use the restroom. Another resident, R2, claimed they were left unattended in the restroom for approximately 1.5 hours and had been yelling for assistance during this period.
Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D.
Allegation: Staff are not provided with proper training to care for residents.
It was alleged that staff at the facility are not being provided with required training.
LPA reviewed three (3) employee files at random and found two (2) of three (3) staff reviewed had no current CPR training and one (1) of three (3) had no current First Aid training.
Based on observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D.
Continued on additional LIC 9099-C |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/30/2026
Section Cited
CCR
87411(a) | 1
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7 | 87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs….The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This is evidenced by:
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7 | Administrator agrees to submit a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Previous Administrator has provided proof of in-service training conducted on February 19, 2026, addressing this deficiency. |
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14 | Based on observation and interview, the licensee did not ensure that facility staff was sufficient in numbers in that (2) two of (2) residents interviewed stated they had been left unattended after requesting assistance from staff. Additionally, (5) of five (5) staff agreed that the facility did not have enough staff on each shift to properly care for residents, which poses a potential health, safety, or personal rights risk to residents in care. | 8
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Type B
03/30/2026
Section Cited
CCR
87411(c)(1) | 1
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7 | 87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This is evidenced by: | 1
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7 | Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Administrator provided proof of staff’s current First Aid training on November 5, 2026. Additionally, Administrator conducted an in-house CPR training for all staff on November 6, 2025 provided by Kiser CPR. |
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14 | Based on observation and record review, the licensee did not comply with the regulation stated in that one (1) of three (3) staff files reviewed did not have current First Aid training, which poses a potential health, safety, or personal rights risk to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/30/2026
Section Cited
CCR
87211(a)(1)(A) | 1
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7 | 87211 Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any….(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This is evidenced by:
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7 | Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Administrator has provided LPA with an LIC 624A documenting this resident’s death and has been sending incident reports sufficiently to CCL since being notified of the deficiency in October 2025. |
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14 | Based on observation and record review, the licensee did not comply with the regulation stated in that one (1) resident passed away and the facility failed to inform CCL within seven (7) days, which poses a potential health, safety, or personal rights risk to residents in care. | 8
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32 | Staff did not provide assistance to resident in a timely manner.
It was alleged that a resident (R1) had pushed their call button and waited approximately two hours for assistance from staff.
LPA interviewed R1 who stated the same information. R1 stated the facility’s call buttons were inoperable and staff were unable to hear R1 calling for assistance (see substantiated complaint control #59-AS-20251016114017) R1 indicated they had needed assistance using the restroom and was left in their bed for “2-3 hours” after attempting to use the facility call system. R1 further stated “I was soaked and my bed was soaked. This is happening regularly.” R1 was unable to give an approximate day this had occurred.
Five (5) of five (5) staff interviewed denied leaving R1 unattended for more than 2 hours at a time as facility protocol is to conduct checks on residents at least every two hours.
LPA reviewed facility care notes which stated “This morning when care staff went in to check on resident they found that (R1) was soaked head to toe in urine due to resident completely refusing to have care done during the night because (R1) says (R1) does not want to be woken up i told (R1) that it is the law that care staff change (R1) and check (R1) every 2 hrs (R1) said well if i hit them its not (R1) problem notified rcc of (R1) behavior and faxed (R1) MD. No other concerns at this time.” LPA noted two other instances in the care note records where R1 refused changes by care staff.
Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED
Multiple residents experiencing falls at facility while in care of staff
It was alleged that several residents were experiencing falls while in the care of staff.
LPA reviewed care notes and incident reports that were documented between July 1, 2025 and October 14, 2025, which indicated there were four (4) residents who had sustained five (5) falls total in this period, with one resident falling twice. According to the care notes, all the falls documented were unwitnessed and care staff called Emergency Medical Services immediately upon discovering the residents had fallen and assessing for injury. Although record review does indicate residents had experienced falls, the amount recorded during the 3-month period does not indicate an excessive or “abnormal” number of falls and all the falls were reported as unwitnessed, not while in the direct care of a staff member.
LPA interviewed administrator who stated the care plans of each resident who had experienced a fall were updated as needed.
Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator, Grace Hawkins, via email. |