complaint·March 18, 2025

During the investigation process, and review of the resident’s (Resident 1) observation log, it was reported that on 01/15/25, 01/18/25 and 01/20/25, the resident was complaining of shoulder pain. Staff reported that they advised upper management of the resident’s pain, which was their protocol to have the resident sent out by emergency services. The management did not send the resident out until 01/21/25, which was six days later. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Facility staff did not report change in condition to authorized representative . During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. During the investigation process, it was reported that the resident’s (Resident 1) responsible party was not notified of the initial complaint of the resident’s shoulder pain. It was reported that it was at least six days later before the responsible party was notified. The regulations state that when changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. The contents of this page has been removed, see LIC 9099 dated 03/25/25. Facility staff do not meet the needs of residents in care . During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. During the investigation process, nearly all staff reported that staff are not meeting the needs of residents in care. It was stated that generally there are two care providers and one medication technician for 30 plus residents. It was reported that frequently a staff person will “call out” meaning not come to work, which then leaves one care provider and one medication technician to take care of 30 plus dementia residents. Staff reported that it is impossible to ensure that all residents are showered on their scheduled shower day and that their needs are not being met. Part of the allegation included that the resident’s were not seeing a podiatrist. The administrator provided documentation that a person from a clinic comes to the facility quarterly to provide care for the resident’s podiatry needs. The document indicated that approximately 10 residents received services on 01/20/25. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Facility is malodorous . During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. During the investigation process, it was reported that residents use the common area toilets and that at times the toilets do get clogged and that there is an odor. Staff stated that sometimes resident’s put in too much paper products and this is part of the reason that the toilets clog up. Staff reported that they are responsible for unclogging the toilets as soon as they can. The administrator reported that if there is a problem that cannot be fixed by the staff, she will call a plumber. It was reported that when the toilets are plugged, it may cause a foul odor.