complaint·August 5, 2025

Continue from LIC9099... LPAs P. Manalo and K. Nguyen conducted interviews with 4 residents and 4 staff. Allegation: Staff do not report incidents to appropriate parties It was alleged that staff do not report incidents to appropriate parties. A review of R1’s Resident Daily Log dated 03/09/2025 and Internal Incident Report dated 03/09/2025 and 04/23/2025 revealed that R1 had multiple unwitnessed falls. Falls were made aware to the responsible parties, however, were not reported to the licensing department. Based on interviews conducted with S2, S2 stated that incident reports will only be reported to the licensing department if the resident was sent to the hospital or had any serious injury due to previous training from the facility. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Continue from LIC9099-A... LPAs P. Manalo and K. Nguyen conducted interviews with 4 residents and 4 staff. Allegation: Staff do not ensure that resident's incontinence needs are met It was alleged that staff do not ensure that resident’s incontinent needs are met. A review of Resident’s Continence Care Services dated 04/22/2025 to 04/30/2025 showed that R1 received continence care every 2 hours. However, interviews with S3, S5, S6, and S7 stated that there are times when R1 would refuse continence care from staff. Facility’s invoice with R1’s responsible party revealed that there is a service charge pertaining to R1’s continence care from March 2025 to May 2025. Progress Notes from the Resident Daily Log also showed that S5 assisted R1 with continence care on 03/19/2025 and 03/26/2025. Allegation: Staff do not assist resident with ambulation It was alleged that staff do not assist resident with ambulation. Interviews with ED, S1, S3, S4, and S5 stated that R1 did not have escort services included in their Service Plan, however, staff will still assist R1 with escorting services to the dining hall when needed. Record review of the Resident Daily Log had progress notes dated 03/19/2025, 03/26/2025, and 04/24/2025 showing that R1 was provided escorted services by staff to the dining hall. Allegation: Staff do not monitor resident for change in condition It was alleged that staff do not monitor resident for change in condition. A record review of the Family Care Conference Progress Detail dated 04/03/2025 showed that the facility conducted a meeting with the responsible party regarding some concerns with R1’s decline of health condition. The conference included speaking with the responsible party regarding the R1’s assessment and updating R1’s service plan. Continue to LIC9099-C... Continue from LIC9099-C... Allegation: Staff do not communicate with responsible party regarding resident's care It was alleged that staff do not communicate with the responsible party regarding resident's care. Based on interviews conducted with S2, S2 stated that most of the communication between the facility and R1’s responsible party was conducted via phone call and email. Record review of text communication correspondence dated between 03/26/2025 to 03/27/2025 showed that staff communicated with R1’s responsible parties via text regarding R1’s care. Record review of email communication between R1’s responsible parties and the facility revealed that the facility communicated about R1’s care plan and continence care between September 2024 and October 2024. A record review of the Family Care Conference Progress Detail dated 04/03/2025 indicated that the facility and family had a meeting regarding R1’s care and the facility’s plan on providing that care to R1. Allegation: Staff handles resident in a rough manner It was alleged that Staff handles resident in a rough manner. Interviews with 4 of 4 residents stated that staff are handling them with care when providing services to the residents and have not observed or heard of any staff being rude to the residents. R2 indicated that when staff are assisting R2 with ADLs, R2 has not had any negative encounter or experiences with staff. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There is no deficiency noted. Exit interview conducted and a copy of this report was provided.