Staff informed of instances where there was one (1) caregiver responding to all Assisted Living residents, and staff informing residents that they would return but never coming back to assist them. Staff interviews showed that that staff attempted to assist residents timely, but insufficient staffing had resulted in residents waiting for long periods of time for assistance. Staff informed that families have confronted them about only one (1) staff member working the floor and there not being enough help for residents.

Outside source interviews were mixed regarding resident wait times. One outside source informed observing resident wait times between 5-10 minutes. A second outside source informed that staff did not respond for 30 minutes when their resident pushed their pendant for help. A third outside source did not have specific wait times for pendant responses, but expressed concern with how few staff have been observed assisting the residents in memory care. The third outside source informed that staff have admitted that there were not enough caregivers on each shift to meet the residents' needs.

Review of facility call button records during the timeframe of complaint revealed that between 01/19/25 11:28pm to 01/24/25 2:59pm, within less than a 5-day period, there were 55 pendant calls with wait times 20 minutes or above, with the longest recorded time being 86 minutes (18 pager announcements to staff) and one call with which there was no response by staff (21 pager announcements to staff before the announcements ceased). This record corroborates the reporting party statements as well as staff and resident interviews that residents commonly waited for extended periods for staff assistance.

Regarding the allegation, "Licensee did not ensure chemicals were properly stored", it was alleged that hazardous chemicals were accessible in a first floor storage room and on an outdoor patio. Staff members who were interviewed consistently denied observing or being aware of any chemicals that were accessible to residents. No staff members interviewed had been informed by any resident that chemicals were not properly stored.

An outside source informed that a door to a room containing chemicals on the first floor was unlocked during a visit. A second outside source denied observing any chemicals that had been improperly stored or made accessible to residents.

During unannounced facility visits on 01/24/25 and 02/21/25 LPA directly observed the first floor laundry room unlocked and unattended by staff. (Continued on LIC9099-C p. 3)

LPA observed cleaning chemicals in unlocked cabinets within this room. During the facility visit on 02/21/2025 LPA observed unsecured plant chemicals and insecticide on the 3rd floor patio.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report, the and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Staff interviews informed that R1 was at baseline the day before and the day of their death. Staff informed that R1 had been observed participating in social activities and resting in their room a few hours prior to their passing. The staff interviewed informed that there were no indications of concern. The information provided by staff was partially inconsistent from the care notes, which documented that R1 was exhibiting symptoms outside of their baseline prior to their passing.

Review of facility care notes revealed that R1 experienced a change in condition the day prior to passing away, with increased fatigue and inability to consume medications or food. The care notes showed that staff conducted wellness checks and contacted R1's hospice agency regarding their condition. The Death Report submitted by the facility stated that R1's cause of death was "End of Life Parkinson, pulmonary disease" (sic). The Doctors Worksheet for Death Certificate, dated 01/22/25, completed by a Medical Examiner, stated that R1's immediate cause of death was Cardiorespiratory Arrest, due to End Stage Parkinson's. Additional records of resident pendant response times showed that R1 pushed their pendant the morning of their passing, and staff responded after 41 minutes.

Outside source interviews did not corroborate the allegation. Two licensed outside medical professionals familiar with R1's care informed that R1's cause of death was related to their end-stage diagnosis and a cardiac/respiratory event. One outside source stated that they assessed R1 the day before their passing and they were observed to be experiencing lethargy and a lowering heart rate. The outside source did not observe any neglect or lack of supervision from facility staff and did not believe that caregiver supervision contributed to R1's passing. Both outside sources were asked if the possible delay in response time to R1's pendant call contributed to R1's passing. Both medical professionals informed that the staff response time was not related to R1's passing, as R1 was receiving end-of-life care and was on Do Not Resuscitate (DNR) status. Due to this status, no life-saving interventions would have been implemented for R1, as the condition that caused them to pass was a natural progression of their end-stage disease. The outside sources did, however, express concern that R1 may have been unnecessarily uncomfortable or possibly in distress during their passing if pain medication was needed for comfort.

The records and interview evidence shows that R1's death was a natural progression of their end-stage disease and did not indicate culpability of the facility for R1's death. Additionally, the evidence showed that staff monitored and checked on R1 according to their care plan and contacted the Hospice agency with changes of condition. (Continued on LIC9099-C p.3)

Regarding the allegation, "Licensee did not provide adequate food service to residents", it was alleged that residents were being fed unsanitary/rotten foods, and that staff did not assist residents with feeding. Staff members interviewed denied observing unsanitary or rotten food being served to residents. Staff members informed that some staff eat at the facility and no concerns were noted. Additionally, staff informed that all residents in Assisted Living were capable of feeding themselves, and limits existed regarding the extent to which staff were allowed to help a resident eat, due to the facility not being skilled nursing.

Outside source interviews did not corroborate the allegation. Outside sources confirmed directly observing meals served at the facility, an no meals were observed to be rotten or unsanitary. No residents had reported to the outside sources that the food was not of good quality.

Review of food menus during the timeframe of complaint were reviewed. The documents revealed that the food item of concern, which staff were alleged to have not assisted residents with eating, was only offered on the "Always Available Menu" and not given as a regular entree. This showed that residents would have had to intentionally order the item for it to be prepared for them outside of the entrée item.

During five (5) unannounced facility visits LPA directly observed the food service at the facility. LPA observed dining staff tending to residents, and food accommodations such as meat cut up upon request. During certain visits LPA spoke to residents in the dining room, inquiring about the food. The residents stated the food was good and did not express concern about unsanitary or rotten meals. LPA also observed the cooking equipment used to prepare meals; the kitchen was clean, sanitary, and organized without issue. An outdoor grill was found to have dried food particles, however, interviews revealed that it had not been used in many months and no evidence existed that food was being cooked on the barbecue without being cleaned, or that dried food particles were being fed to residents.

Regarding the allegation, "Licensee did not ensure facility was in good repair", it was alleged that the ADA accessible doors did not open upon pushing the button and a balcony patio was hazardous/unsafe. Staff interviews revealed that the push button to the first floor back patio had been disconnected due to a malfunction and was in process of being repaired. Staff members interviewed denied having knowledge or observations of the second or third floor patios being hazardous or in disrepair.

Staff denied that any resident had expressed concern about either balcony patio. Staff interviews further revealed that the second floor patio was temporarily closed due to the remodeling of the second floor dining room, which the patio balcony was connected to.

Outside sources interviewed denied having observations of the second or third balcony being in disrepair. Outside sources denied that any resident had expressed concern regarding the safety of the patio balconies.

No records were found to refute or corroborate the allegation.

During an unannounced facility visit LPA directly observed the patios in question. The second floor patio was inaccessible due to it only being able to be accessed through the dining room on that level, which was closed due to remodel. LPA observed both patio balconies to be free of clutter. LPA observed both patio balconies to be of sound structure, with high concrete and glass walls well over head height, with safety features. Both second and third patio doors were manual without push button features.

Regarding the allegation, "Licensee did not ensure facility temperature was within the required range", it was alleged that an area of the facility was abnormally cold. Staff interviews were consistent regarding the temperature of the 3rd floor being cold. Maintenance staff informed that the temperature was due to the cooling feature of the recently installed boilers, an issue which was in the process of being fixed. Staff informed that the low temperature did not affect the resident rooms and was isolated to a specific hallway. Staff informed that each resident room had an individual thermostat that each resident could adjust to their comfort.

An outside source informed observing the area of concern and recalled that the temperature felt approximately in the 60's but they did not have an observation of the thermostat to know the exact temperature. A second outside source was unaware of any portions of the facility being significantly cold.

Facility records corroborated staff statements that the issue was in the process of being addressed. Review of email invoices and text messages between management and outside contractors showed that the Licensee was attempting to correct the issue and did not delay in attempting to correct it.

Continued on LIC9099-C p.5)

During an unannounced facility visit on 01/24/25 LPA directly observed the area of the facility in question. LPA observed the temperature to decrease in the hallway outside of the 3rd floor boiler room. The same hallway farther away from the boiler room was shown to be warmer, 71 degrees, according to the thermostat.

During an unannounced facility visit on 02/21/25 LPA directly observed the same hallway to be nearly consistent in temperature throughout. This corroborates staff statements and records regarding ongoing repairs, and that the issue was corrected.

While a portion of the facility was found to be low in temperature, the evidence showed that the Licensee did not allow it to remain unaddressed, and made efforts to fix the issue.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.