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13 | Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 07/24/2026 to deliver findings related to the above allegation. LPA was greeted by Executive Director Jeri Hillery and explained the purpose of the visit.
The investigation included a review of the facility's resident roster, staff roster, maintenance logs, maintenance work orders, elevator service records, plumbing work orders, resident maintenance requests, resident notifications regarding repairs, and other documentation related to facility maintenance concerns. LPA conducted interviews with ten residents (R1–R10) and five staff members (S1–S5), including the Maintenance Director. Additionally, LPA toured the facility and observed the elevators, dining room during meal service, common areas, hallways, resident rooms with reported maintenance concerns, restroom facilities, and air conditioning units to assess the allegations regarding elevator delays, plumbing issues, air conditioning concerns, and the facility's response to maintenance requests.
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32 | Allegation: Staff do not provide a safe and comfortable environment for residents.
It is alleged that staff do not provide a safe and comfortable environment for residents due to extended elevator wait times, delayed maintenance repairs, unresolved plumbing issues, and air conditioning concerns, resulting in inconvenience, discomfort, and delays in residents' access to meals and other areas of the facility. The investigation revealed that one of the facility's two elevators had been out of service for approximately one and a half weeks due to a failed compressor that was on back order. Interviews with S1–S5 confirmed that only one elevator remained operational during the outage. Although staff implemented interim measures, including meal delivery to resident rooms upon request, escorting residents requiring assistance to the dining room before peak meal times, and encouraging ambulatory residents to use the stairs, residents continued to experience extended wait times for the operational elevator.
Interviews with R1–R10 consistently confirmed the elevator outage caused significant inconvenience. Residents reported waiting between 10 and 45 minutes for the elevator, particularly during peak meal periods when many residents traveled to the dining room between approximately 11:00 a.m. and 11:30 a.m. Several residents reported altering their schedules to avoid the busiest times, while others expressed frustration with the prolonged waits and the impact on their daily routines. The investigation further revealed delays in addressing maintenance concerns. S2 reported inheriting approximately 64 outstanding work orders upon assuming the position. Staff acknowledged that maintenance response times had been delayed due to the absence of maintenance personnel prior to the new hire. Residents reported maintenance requests were often not completed promptly and stated they frequently did not receive updates regarding the status of submitted work orders. One resident reported their air conditioning unit had not been functioning properly for over one month and that, despite repeatedly notifying staff, the issue remained unresolved at the time of the investigation. Although the resident had been provided with a fan, replacement of the air conditioning unit was still pending. While the facility had begun addressing the maintenance backlog and implementing corrective actions, the evidence demonstrated that residents experienced ongoing inconvenience and discomfort due to delayed maintenance repairs, prolonged elevator wait times, delayed replacement of air conditioning units, and inadequate communication regarding maintenance requests and repair timelines.
(continued on 9099C) |
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32 | Allegation: Staff do not ensure facility is in good repair.
It is alleged that staff do not ensure the facility is maintained in good repair due to delayed maintenance repairs, prolonged response times to resident maintenance requests, unresolved work orders, delayed replacement of air conditioning units, and inadequate communication regarding the status of maintenance requests. The investigation revealed the facility experienced a period without maintenance staff prior to hiring a new Maintenance Director. Interviews with S1–S5 confirmed maintenance requests were submitted through the facility's work order system; however, staff acknowledged delays in completing repairs. S2 stated they inherited approximately 64 outstanding work orders upon beginning employment and prioritized plumbing repairs and other urgent maintenance issues. S2 also reported several air conditioning units had been repaired, while additional units remained pending replacement through the corporate office. S4 and S5 stated their role is limited to creating maintenance work orders for reported concerns. Once submitted, responsibility for repairs shifts to the maintenance department. Both staff members stated they are not routinely updated by maintenance or management regarding the status of repairs and are therefore unable to provide residents with updates when asked. S5 stated they occasionally submit additional work orders if residents report the issue remains unresolved. The majority of residents interviewed (R1–R10) corroborated staff statements regarding delayed maintenance response times and limited communication. Residents reported that repairs were eventually completed but often took longer than expected and that they were not informed of repair timelines or the status of their work orders. Many residents were unaware a new Maintenance Director had recently been hired. R1 reported an air conditioning unit had not been functioning properly for over one month despite previously reporting the issue and, although provided with a fan, the unit had not yet been replaced at the time of the investigation. Records reviewed confirmed the facility had a significant backlog of maintenance requests before the new Maintenance Director assumed the position. Although the facility had begun addressing the backlog, the investigation determined that delayed maintenance response times, delayed replacement of air conditioning units, and inadequate communication regarding maintenance requests resulted in ongoing inconvenience to residents.
Based on LPA's interviews which were conducted 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, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/21/2026
Section Cited
ILS
87303(a) | 1
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7 | (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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7 | The facility shall submit the following to the LPA by the POC due date:
A written plan for tracking, completing, and communicating maintenance requests.Proof that the outstanding air conditioning units have been repaired or replaced.Proof of staff training on the revised maintenance work order and communication procedures. |
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14 | Based on interviews and records reviewed, it was determined that the facility failed to ensure the facility was maintained in good repair by not timely addressing maintenance requests, resulting in a backlog of approximately 64 work orders, delayed repairs, delayed replacement of air conditioning units, and inadequate communication with residents regarding the status of maintenance requests. This posed a potential health, safety, and personal rights risk to residents wihich poses/posed an immediate risk to the resident's health, safety, and personal rights. | 8
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Type B
08/21/2026
Section Cited
CCR
87468.1(a)(2) | 1
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7 | (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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7 | The facility shall submit the following to the LPA by the POC due date:
1. A written plan describing how residents' comfort and safety will be maintained during equipment outages or other conditions affecting accommodations.
2. Documentation demonstrating residents are offered reasonable alternatives or assistance (e.g., meal delivery, relocation, fans, or other accommodations) when services are disrupted.
3. Proof that staff have been trained on ensuring residents' personal rights to safe, healthful, and comfortable accommodations during service interruptions.
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14 | Based on interviews and records reviewed, it was determined that the facility failed to ensure residents were provided safe, healthful, and comfortable accommodations by not timely addressing maintenance issues elevator outage delay updates, delayed air conditioning repairs, and a backlog of maintenance work orders, resulting in inconvenience and discomfort to residentswihich poses/posed an immediate risk to the resident's health, safety, and personal rights. | 8
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