complaint·October 31, 2024

Continued from LIC9099. care. R1 stated that S4 would come in her room and tell her that he wanted to be her boyfriend and lifted her shirt and kissed her breast. R1 also stated S4 made inappropriate sexual comments referring to her private areas. S4 was employed through an agency called Serving Seniors Care from May 2020 to December 2021. Staff member (S5) revealed that R1 had complained that one of the outside agency staff was inappropriate towards her, but S5 never heard what the inappropriate behavior was. On April 27, 2023, the Department interviewed W1. W1 stated R1 had told him that one of the male staff members said disgusting things to her and the male staff member also kissed her breasts. An interview with Serving Senior Care staff, (S7), revealed that he/she was aware that S4 was harassing R1 and was aware that S4 had said something sexual to R1. During an interview with suspect, S4, admitted that he told R1 that he wanted to be her boyfriend, asked if he could kiss her, and stated that he made inappropriate sexual comments while he was changing her. S4 said he told R1 those things as a joke and that he knows that it was inappropriate. Allegation: Staff made sexually inappropriate comments toward a resident. Interview with R1 on April 3, 2023, revealed that S4 would come into R1’s room and tell R1 that he wanted to be her boyfriend and look at her naked body, which made R1 uncomfortable. S4 also used inappropriate sexual language to refer to R1’s private area. During an interview with S4 on June 15, 2023, S4 admitted to using sexual language and making inappropriate sexual comments towards R1. S4 stated he was joking and admits he was wrong in making those comments. Continued on LIC9099C. Continued on from LIC9099C. Allegation: Staff left resident on the floor after a fall for a prolonged period of time Based on an interview with S1 it indicated that R2 was receiving services through an agency called SafelyYou . This service is used to monitor resident unwitnessed falls. S1 stated the system is that if a resident falls, SafelyYou is alerted and immediately contacts the facility and if no one at the facility answers SafelyYou has an additional contact number for the staff at the facility. The staff answering the call from SafelyYou goes to check on the resident. On the day in question, the Department reviewed the time sequence received from the facility regarding R2’s unwitnessed fall and the total time to respond to R2 was 1 hour and 10 minutes. S10 stated she received three (3) calls from SafelyYou to check on R2 and she had notified the person on duty each time a call was received. During the interview with S2, she stated she was working on both floors on the day of the incident, and she did not answer the phone when the agency called because she thought it was a scam call. S2 also stated when S10 told her to check on the resident she then went upstairs to check on her. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal rights and a copy of this report provided. Continued from LIC9099. residents. The med techs stated the steps are to push the cart to each room, pour the medication into a cup, pass the cup to the resident, and make sure the resident takes the medication. All three (3) also stated the medication cart is never left unlocked when unattended. The allegation is Unsubstantiated. Allegation: Questionable death During record review the Department reviewed the death report received from the facility on December 21, 2 023, that stated R2 had expired, but did not state a cause of death. During the investigation the Department obtained a copy of R2’s death certificate; it stated R2’s cause of death as natural causes. Allegation: Staff did not ensure resident's dietary needs were met. The Department interviewed three (3) staff that worked in the kitchen. S13 stated he is given a form from the residents for room service which specifies the residents’ request. If a resident requests diary to be added to their food, it is put on the side not into the food. S14 stated the food that is taken to the residents’ rooms is put on trays and condiments are put on the side for them to add themselves. Based upon the interviews and information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report provided.