Ivy Park at Otay Ranch.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein. CCR 87466 states, “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…” Per Licensee’s “Fall Management Protocol” written policy, all falls, witnessed or unwitnessed, “will require completion of an Unusual Occurrence Report and an investigation of the circumstances leading to the fall,” and “any resident sustaining a fall will also be placed on Alert charting status.” The policy further states that an “internal Incident Report (Form 406a) is completed every time a resident falls,” and the “the [resident's] healthcare practitioner will be notified using Form 213a, Physician Fax Report of Fall.” Review of records and interviews of staff and outside sources showed: Resident #1 (R1) fell just outside the facility’s main entrance door on 03/22/2025. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The responding facility staff, Staff #1 (S1) and Staff #2 (S2), did not timely inform any medication tech, nurse, or manager about this fall. No internal Incident Report (Form 406a) was completed for this fall around when it occurred. Also, Licensee did not timely submit an LIC624 Unusual Incident/Injury Report to CCLD for this fall (this latter element was already addressed/cited in a separate complaint report). R1’s primary care physician (i.e., the pertinent healthcare provider) was also not timely notified of R1’s fall via a Form 213a, or by any other means. [CONTINUED ON LIC 809-C, 1 of 2] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] During his own 06/02/2025 site visit, LPA requested from Licensee copies of the facility staff’s charting and/or progress notes, which would evidence that “Alert charting” was performed on R1 post-fall. However, facility managers replied that no such notes existed which could prove that R1 was placed on “Alert charting status,” as was required by Licensee’s own written policy. As confirmed in administrator interview, Licensee defined “Alert charting” as the facility’s licensed nurse meeting with the resident face-to-face daily, for at least three (3) consecutive days after the fall, to assess the resident’s health and ask about their experienced symptoms, and to document these findings in electronic progress notes. “Alert charting” is therefore more than a cursory observation of the resident in passing, by lay staff.] Staff interviews showed: By 03/29/2025, Staff #4 (S4), the facility medication technician who called/arranged an ambulance for R1’s confusion and elevated blood pressure, was still unaware that R1 had fallen a week earlier. Likewise, the nurse manager then overseeing the facility’s clinical operations, Staff #5 (S5), and their deputy supervisor, Staff #7 (S7), both did not become aware that R1 had fallen a week earlier, until after R1 was already at the hospital. While there is no regulation specifically addressing internal communication, the failure of staff to internally communicate in this instance evidenced Licensee falling short of its own policy/procedural requirements regarding post-fall observation of R1. (In the final analysis, CCLD’s investigation showed that R1’s fall was not a proximate cause of R1’s confusion or elevated blood pressure. However, S4, S5, and S6 each affirmed to LPA that knowing about a prior fall provides useful context needed to inform subsequent observation checks and incidental medical care decisions, and that S1 and S2 should have reported the fall per protocol, when it occurred.) Additionally, during an earlier 06/23/2025 site visit, a California Department of Social Services (CDSS) Investigator (a peace officer acting in an official capacity on behalf of CCLD) formally requested from facility manager S5 a copy of the surveillance camera video footage segment depicting R1’s aforementioned fall on 03/22/2025. As of the date of this 06/23/2025 request, the pertinent footage was still intact and viewable, as witnessed by the Investigator. The Investigator made multiple follow-up phone calls to S5 for a copy of this footage for CCLD’s case file, but it was not provided to the Department. The Investigator subsequently spoke to the new facility administrator on 10/03/2025, who reported that as of that date, the pertinent footage no longer existed. [CONTINUED ON LIC 809-C, 2 of 2] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809-C, 1 of 2] Two (2) deficiencies were cited according to California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

R1's Individualized Service Plan dated August 15, 2025 states that R1 is ambulatory and is unable to leave the facility unsupervised. Service plan further states that R1 is required to wear their safety bracelet if they are in the assisted living section of the community. LPA interviewed R1 who stated that less then a week ago they exited the facility without any supervision. R1 stated that they wanted to take a walk so they walked down the stairwell and exited the facility onto the sidewalk. R1 stated that they did not injure themselves during their walk but they did feel dehydrated. R1 stated that they now have a private caregiver who takes them for walks outside of the facility LPA interviewed Staff 1 (S1) who stated that on the date of the incident a woman called the facility advising staff that a person was found walking down the sidewalk who appeared lost and confused. The woman was able to confirm with R1 their identity. S1 then drove to pick up R1 who was with law enforcement. S1 asked R1 "what happened." R1 replied that they went for a walk and got lost. S1 stated that R1 was located approximately three blocks from the facility. S1 was unable to confirm how long R1 was outside of the facility unsupervised. LPA interviewed Staff 2 (S2) who stated that R1 eloped from the facility on the second day that R1 was admitted. S2 stated that R1 resides on the second floor in the assisted living section of the facility. S2 stated that R1 exited the facility from a stairwell on the second floor that exits onto the sidewalk. S2 stated that R1 was out of the community for approximately two hours. S2 stated that R1 was picked up by S1 and brought back to the facility. S2 stated that R1 now has a private caregiver that was provided by R1's responsible party. On September 3, 2025 CCL received an incident report (IR) regarding R1. IR stated that on September 2, 2025 the facility received a telephone call from a neighbor advising them that R1 was seen walking by the nearby homes. R1 was immediately picked up by facility staff. R1 returned to the facility without any visible injuries. After R1 showed facility staff the exit they took, staff concluded that they "cleared the alarm" without realizing that a resident had exited the facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Department has investigated the complaint alleging staff did not prevent R1 from eloping from facility. Based on evidence obtained R1 eloped from the facility on September 2, 2025. Accordingly, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted, a plan of correction was developed by Trobell Orana and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Trobell Orana whose signature on this form confirms receipt of the documents.

[CONTINUED FROM LIC 9099] Interviews and records showed: R1 was independent in care and medications, paying Licensee only for room and board. On 03/29/2025, R1 was transported to the emergency room, where they were admitted and hospitalized. On 04/09/2025, R1’s responsible person (RP) vacated R1's apartment of belongings, relinquishing control of the room to Licensee. Licensee continued to bill R1 for room and board through 05/09/2025, which was initially consistent with the 30-day move-out notice provision in R1’s residency agreement, so long as R1 was alive. However, R1 died at the hospital on 04/25/2025, as confirmed by their official death certificate from the county. On 04/30/2025, R1’s RP notified Licensee that R1 had since died, and Licensee replied to confirmed receipt. R1’s admissions agreement states, “Death of Resident: This Agreement shall terminate automatically upon your death.” Furthermore, California Health and Safety Code Section 1569.652 specifies in part, “(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.” R1’s admissions agreement also states that in cases where a resident has died, “Within fifteen (15) days after your personal property is removed from your apartment, your estate, or other person or entity responsible for payment of fees under this Agreement, will receive a refund of any fees paid in advance covering the period after your personal property has been removed.” This 15-day refund deadline is also consistent with California Health and Safety Code. As of the commencement of CCLD’s investigation on 06/02/2025, Licensee still had not credited/refunded C1’s account/estate for room and board fees from 04/26/2025 through 05/09/2025, as were owed. Additionally, records and interviews showed: Earlier on 11/10/2024, R1 spent $114.88 on pest control products for their facility apartment, in response to seeing mice in their room. Upon discovering this expenditure, R1’s RP spoke with a facility manager, who agreed to speak with the facility administrator regarding a credit/refund of this money. This manager claimed they did speak to the administrator about this. However, the RP told CCLD they did not receive a follow-up response from Licensee, one way or the other. [CCLD’s subsequent investigation substantiated the earlier presence of mice in R1’s facility apartment, based on witness testimony and photographic evidence.] During today’s visit, Licensee agreed to additionally credit/refund this incidental amount to R1’s account/estate. [CONTINUED FROM LIC 9099-C, 2 of 2] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 9099-C, 1 of 2] Based on records and interviews, a preponderance of evidence exists to show Licensee earlier did not issue refund as required to R1. The allegation was therefore Substantiated, and one (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction were jointly developed with the Licensee. An exit interview was conducted with Zuluaga, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

[CONTINUED FROM LIC 9099] Interviews aligned to show: On 03/22/2025, R1 fell on the facility premises, right outside the lobby front door, to which facility staff responded timely. On 03/29/2025, facility staff arranged for R1 to be transported to the hospital for a change in condition, where R1 was admitted. R1 remained at the hospital, where they subsequently died in late April 2025. Licensee did not submit written incident reports to CCLD or R1’s responsible person describing R1’s fall, hospitalization, or death; these were required to be submitted to both parties within seven (7) days of occurrence. Interviews of a corroborating outside source showed this person found two (2) mice hiding inside a cardboard box inside R1’s bedroom, which they removed and brought outside. CCLD also obtained photographic evidence of rat multiple droppings on R1’s personal effects. Available records and interviews showed: R1’s and their representative/responsible person (RP) both previously signed an Admissions Agreement which Licensee prepared for R1. However, a facility representative did not co-sign on behalf of Licensee. [Licensee’s missing signature will be addressed in a separate Case Management visit report.] R1’s RP then requested a copy of the contract from Licensee, but Licensee did not follow through on this request. Based on records and interviews, a preponderance of evidence exists to show Licensee did not meet reporting requirements, that Licensee did not keep resident’s room free of rodents, and that Licensee did not provide copy of admissions agreement to resident’s representative. These allegations were Substantiated, and three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Anguiano, to whom a copy of this report, the LIC 9099-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Calais Anguiano. Former Resident #1 (R1) and their representative/responsible person (RP) signed the Admissions Agreement contract which Licensee prepared and presented to them. [See LIC811 Confidential Names List for a description of R1.] However, a facility representative did not co-sign this contract on behalf of Licensee, even after seven (7) days after move-in. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Anguiano, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

LPA attempted to interview R1 on May 14, 2025. R1 was unable to answer qualifying questions. R1 was unable to state the date or time. LPA then asked R1 basic questions regarding leaving the facility unattended. R1 stated that they have left the facility in the past but not recently. LPA interviewed R2 who stated that they have lived at the facility too long. R2 stated that they were recently thinking about walking across the street and catching a bus. R2 stated that in the past when they tried to leave the facility unsupervised a staff member yelled at them to get their walker. R2 stated that last month they left the facility and walked to the intersection by themselves. LPA interviewed S1 who stated that the memory care unit was conducting an "elopement drill" right before the incident occurred with R1. S1 stated that the caregiver assigned to R1's section claimed that they "cleared their section." S1 stated that the egress door alarm sounded a short time after and the staff conducted a head count of residents. S1 stated that as they were driving away from the facility they saw R1 outside on the sidewalk area. S1 stated that they placed R1 in their car and drove them back to the facility. S1 stated R1 had no injuries and they estimate that R1 was out of the facility for approximately 10 minutes before R1 was located. LPA interviewed S2 who stated that while driving to work on April 26, 2025 they saw R2 walking towards the street intersection of Olympic Parkway and East Palomar Street. S2 stated that they were worried and immediately called their supervisor to advise them where R2 was located. S2 stated that they do not believe R2 had any injuries as a result of the elopement. S2 stated that R2 lived in the assisted living section of the facility and has eloped from the facility more then three times. LPA interviewed Outside Source 1(OS1) who stated that the facility staff called them immediately after the incident and advised OS1 that R1 "got out of the facility through the back." OS1 stated that the Director contacted OS1 the following day and was apologetic for what occurred. OS1 stated that they do not believe it was a major incident since their were no injuries and R1 simply slipped out. OS1 stated that R1 has never eloped before and they have full confidence in the facility staff. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA interviewed Executive Director (ED) who stated that on the date of the incident memory care staff were conducting an "elopement drill" and R1 exited the unit. ED stated that the alarm sounded and a head count and room checks were conducted. ED stated that care staff did not accurately count the residents and failed to alert that R1 was missing. ED stated when staff checked the memory care exit door area R1 had walked to far along to be seen. ED stated that the care staff that did not accurately count the residents was place on suspension and was later terminated. ED stated that R2 goes out for walks since their physician's report states they can leave the facility unassisted. ED stated that R2 did walk to the intersection by the facility and R2's family just requests that they do not get lost. Records review revealed an incident report for R1 was submitted to CCL on March 13, 2025. Incident report stated that on March 6, 2025 the memory care egress door alarm sounded off at 410pm. Facility staff did not locate a resident in the surrounding area and conducted a head count. Facility staff located R1 at 417pm outside of the community, walking on the sidewalk. No injuries were noted. Records review revealed R1 had a diagnosis of Alzheimer's. R1 was unable to leave the facility unassisted and R1 was a high elopement risk due to resident expressing they wanted to leave the facility. Records review revealed R2 had a diagnosis of Encephalopathy and a traumatic brain injury with loss of consciousness. R2's physician's report indicated that R2 was non-ambulatory and R2 was able to leave the facility unassisted at their families discretion. R2's care plan stated that R2 had a cognitive impairment, was unable to leave the community unsupervised and they are required to wear a safety bracelet if in assisted living. The Department has investigated the complaint alleging staff did not prevent residents from eloping from facility and staff did not report incidents to appropriate parties. Based on evidence obtained R1 and R2 eloped from the facility and R2's elopement was not reported to the licensing agency. Accordingly, the above allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. The deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted, plans of correction were jointly developed, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Calais Anguiano, Executive Director. Signature on this form confirms receipt of the documents.

Agency care notes indicated that R2 was awake, alert and verbally responsive. No reports of pain or cough noted. Recommendations included; keep nails trimmed and apply sarna lotion prn. Outside agency did not observe or document R2 being left in feces or unbathed. Facility internal care notes dated May 2021 through April 2022 indicate R2 was regularly monitored and assessed by facility staff. Care notes indicate R2 was monitored for both R2's mental and physical well being. R2's responsible party was also advised of any change of condition. R2's service plan dated Jan 1, 2022 indicated that R2 needed assistance with incontinence supplies, hygiene, and changing linens. R2 would be toileted day and night. Service plan further indicated that R2 would receive assistance with toileting according to R2's schedule, need, and requests. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Calais Anguiano. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Calais Anguiano whose signature below verifies receipt of these rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The other two staff members acknowledged that staffing was a problem and they are often required to work very hard but that resident's needs were being met. Review of internal logs was conducted. The call alert logs from the facility reflected an ongoing concern with long wait times for care. In one week analyzed over 13% of resident calls were answered after 20 minutes or more. Some resident calls took over an hour to answer. LPA interviewed Executive Director (ED) who stated that she began working at the facility on July 2023. ED stated that as of today the facility is sufficiently staffed and the resident pendant calls are answered on a timely basis. ED further stated that the response call time has also improved from the previous year. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted with Calais Anguiano and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Calais Anguiano whose signature below confirms receipt of documents.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Brittany Blaul. Today's visit was in response to two (2) SOC341 Reports of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/07/2023 and 02/01/2024, respectively). Per the first SOC341: it was alleged that Resident #1 (R1) had around $300 in cash stolen from their wallet sometime between 11/21/2023 and 12/06/2023. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Per the second SOC341: R1 had another $250 in cash stolen from their wallet sometime between 01/29/2024 and 01/31/2024. During today’s visit, LPA performed a brief facility tour and collected copies of and reviewed pertinent care and personnel records, visitor logs, theft logs, and investigative notes. LPA also interviewed relevant staff. R1, who was a hospice care patient, passed away on 02/09/2024 and was unable to be directly interviewed by CCLD. Regarding the first theft incident (i.e., $300) against R1, records and staff interviews showed: Licensee learned of the cash loss from R1’s responsible person (RP). Licensee timely reported the loss to CCLD, the Long-Term Care Ombudsman Program (LTCOP), and local police (CVPD). Per manager interview, Licensee’s internal investigation involved interviewing R1, who at that time, was of sound mind and a reliable historian. R1 told Licensee that they clearly saw Staff #1 (S1) take $300 in cash from their wallet. A review of personnel records showed that Licensee ended S1’s employment on 12/15/2023 for an unrelated reason, per the written termination notice. However, manager interview revealed that R1’s testimony about the first theft incident was a contributing factor towards R1’s termination of employment. The facility’s LIC9060 Theft and Loss Record corroborated that one of the “Action[s] Taken / Follow Up” for the first theft incident against R1 included “term of employee.” [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] Regarding the second theft incident (i.e., $250) against R1, records and staff interviews showed: Licensee learned of the cash loss from R1’s RP. Licensee timely reported the loss to CCLD, LTCOP, and CVPD. Per manager interview: Licensee’s internal investigation involved interviewing R1, outside sources, and facility frontline staff who were assigned to R1 during the date range of the loss (which was after S1 was no longer working at the facility). Interviews of frontline staff did not reveal any breakthrough in the second case. R1 by the date of the second investigation was less alert, as they were nearing end of life. Manager interview, corroborated by hospice visit notes and the facility’s visitor log, showed: During the date range of the second loss, R1 was visited inside their bedroom by multiple outside personnel, to include hospice agency staff and durable medical equipment (DME) company staff. Hospice notes showed R1 was asleep during at least two of these visits. A preponderance of evidence exists to show that on at one occasion, Licensee’s staff (S1) did not ensure that a resident in care (R1) was protected from theft or loss. One (1) deficiency was cited per California Code of Regulations, Title 22 (see attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violations (TV) per California Health and Safety Code, regarding delayed-egress door signs (see LIC 9102-TV page). An exit interview was conducted with Blaul, to whom a copy of this report, the LIC809-D page, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

A review of documents revealed that in a single 7-day period it took 20 minutes or longer to answer 136 of the 1024 call alerts throughout the facility. For the week analyzed, 13.3% of the alerts took 20 minutes or longer to answer. Interviews revealed that facility staffing had declined specifically the number of care staff working at any given time. As a result, residents wait longer to receive care. This situation was ongoing and potentially affected all resident that required care. On one identified occasion Resident 1 (R1) (A list of confidential names was provided to the facility) pushed their call alert button. When no staff arrived to assist R1, an outside source became aware and attempted to contact staff members on behalf of R1. When no staff member could be reached by telephone, the outside source dialed 911. Documents revealed that facility staff did not respond to call alert for 45 minutes. The local emergency agency responded and found R1 required basic care that facility care staff then provided. The care was only provided after the emergency staff responded to the facility. Based on the evidence obtained during the complaint investigation, the allegation that the facility is not adequately staffed to meet resident’s needs is SUBSTANTIATED, meaning that there is a preponderance of the evidence proving that the alleged violation occurred. An exit interview was conducted with Silvia Garcia, Business Office Manager; a copy of this report and Licensee's Rights (LIC9058) were provided.

Statement from Executive Director (ED) on August 7, 2023 revealed the facility business office was in the middle of a "personnel transition." As a result some of the residents received a rent increase without a 60 day prior notice. ED further stated that they were actively working on issuing rent credits and/or charge reversals for any residents who may have received a rent increase without receiving their 60 day notice. ED stated that they have completed a reversal of the rent increase for R1 and they have also contacted residents and power of attorney's impacted so that they are aware of the credits applied and of any reversals of rent increase that were applied to their account. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted with Calais Anguiano and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Calais Anguiano whose signature below confirms receipt of documents.

Continue from LIC 9099) Both incidents were fully investigated by management who concluded the incidents did occur. Management took immediate corrective action by providing performance management to the staff involved. In addition, on July 27 and August 17, 2023, facility management provided two in-service trainings for all care staff on residents' personal rights, customer service, and personnel standards of conduct. Although, during interviews, most of the residents expressed satisfaction with the service being provided by the care staff, there was sufficient evidence to support the allegation that staff spoke inappropriately to residents. It was also alleged that staff did not attend to residents’ call buttons in a timely manner. During multiple interviews, residents consistently indicated that when they used their call button it took extended periods of time to get assistance from care staff. Some residents indicated they waited longer than one hour and at times even longer before getting the assistance they needed from care staff. A detailed review of some of the residents who raised concerns about the response time confirmed the response times were excessive. A review of the residents' care plans indicated they required assistance with activities of daily living, such as incontinence care, transfers due to limited mobility, and/or water/food service. Other more serious situations reported were residents needing assistance getting up after a fall. None of the residents reported serious injuries from these falls. The residents also indicated, that although not timely, they eventually received the assistance they needed from care staff. A detailed review of three different residents indicated their response times varied from 1 to 2 hours. According to the facility’s standard, the response time should be 15 minutes or less. A detailed review of the Call Button Excessive Response Report (CBERR) for a 2-month period indicated that in June 2023, there were a total of 867 calls that took longer than 15 minutes with an average of 58-minute response time. In July 2023, there were a total of 1,207 calls that took more than 15 minutes with an average response time of 45 minutes. Facility management indicated the CBERR was misleading. Management’s review discovered that some of the service calls were not cleared as complete in the system after care staff had attended to the resident’s needs. However, facility management acknowledged that this was an area of opportunity for improvement and had been providing training to staff to ensure calls were cleared as complete after servicing the resident. In addition, management stated that they identified staffing needs and scheduled staff accordingly to meet this goal. (Continue at LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (continue from LIC9099C) Based on interviews with residents and staff and records review, there was sufficient evidence to support the allegation that staff did not respond to call buttons in a reasonable amount of time to ensure the health and safety of the residents. The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A Deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A copy of this report, LIC 9099D, along with Licensee/Appeal Rights (LIC 9058 03/22) was provided to Executive Director, Angiano at the end of the visit.