complaint·January 28, 2025

During the investigation, it was reported that currently the council meets one time per month and that notes are taken and distributed to the resident representative. Additionally, it was reported that when the previous administrator was involved, she did not take notes for approximately three months and did not respond to the resident council group of their concerns, which was required. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. Staff do not ensure that residents are provided with activities while in care . During the interview process, the assistant administrator, expressions director, activities director and three staff persons were interviewed. Documents received included rental agreements, physician’s reports, resident council meeting notes and staff names and cell numbers. During the investigative process, it was reported by all staff that activities are provided to the residents. There is a full-time activities director that provides activities for the residents on the assisted living side and the expressions director and staff are responsible for ensuring that residents in the dementia side have activities through out the day. The full-time activities director is overall responsible to ensure that activities are provided on both sides of the facility. All staff stated that activities are provided. However, during the investigation, it was reported that for numerous months, the facility van is not being used for activities outside of the facility, as the staff do not have the proper license to drive the van. The regulations state that the facility shall provide activities outside of the facility to include outings as follows: Attendance at the place of worship of the resident's choice, service activities for the community, events such as concerts, tours and plays, participation in community organized group activities, such as senior citizen groups, sports leagues, and service clubs. The admission agreement states that the facility “will provide provision for trips to social functions…” Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. During the investigation, it was reported that residents on the assisted living side of the facility obtain their mail from the mailboxes provided. The staff stated that if the residents receive packages, the staff distribute them. It was stated that on the dementia side of the building, the staff deliver the mail to the residents and to their family representatives. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated . Staff do not ensure that facility is kept clean . During the interview process, the assistant administrator, expressions director, activities director and three staff persons were interviewed. Documents received included rental agreements, physician’s reports, resident council meeting notes and staff names and cell numbers. During the investigation, it was reported by all staff that the facility is kept clean. It was stated that the housekeeper and maintenance worker have a carpet shampooer that they use to spot clean and to shampoo the common areas of the facility. In addition, staff stated that when there is a spill or spot, they advise the housekeeper and maintenance worker of the concern. It was reported that management goes from room to room to point out to the housekeeper when there are issues with the carpets. Facility is also having the carpets professionally cleaned. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated . Licensee does not ensure that staff are adequately trained . During the interview process, the assistant administrator, expressions director, activities director and three staff persons were interviewed. Documents received included rental agreements, physician’s reports, resident council meeting notes and staff names and cell numbers. During the investigation process, several staff persons were interviewed, and it was reported that staff receive training by video for at least two weeks with a training sign off and a training checklist. In addition, staff are provided with training on the floor with another caregiver for 3-5 days and longer if needed. Staff reported that they felt that they received adequate training. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated . Staff do not ensure that residents' care needs are being met . During the interview process, the assistant administrator, expressions director, activities director and three staff persons were interviewed. Documents received included rental agreements, physician’s reports, resident council meeting notes and staff names and cell numbers. During the investigation process, several staff persons were interviewed, and it was reported that Assisted Daily Living (ADL) skills are being met on a daily basis. ADLs included bathing, dressing, grooming, feeding, toileting, and assistance with walking. Observations of the residents is that they appear to be clean and dressed for the day. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated .