complaint·January 22, 2025

Allegation: Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible partes and reviewed resident (R2, R3) documents. Review of incident reports dated 10/16/23 showed that at 11AM two memory care residents (R2, R3) were able to push open the memory care delayed egress side door and managed to walk outside the parking lot without the alarm sounding due to a faulty delayed egress system. LPA interviewed responsible parties (POAs) who stated that R2, R3 were found by a third party who alerted staff to escort them back to the memory care unit. Staff did not know that they were missing. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not ensure adequate supervision is provided resulting in residents eloping from the facility was found to be substantiated. Allegation: Staff do not ensure residents medications are securely stored in the facility Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. LPA reviewed video footage on 05/31/24 around 8:36PM which showed the memory care medication room door was unlocked/open with no staff present inside or outside the medication room. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not ensure residents’ medications are securely stored in the facility was found to be substantiated. 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 dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff did not ensure reporting requirements are being followed Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed residents’ (R2, R3) documents. Review of incident reports dated 10/16/23 showed staff reported two memory care residents (R2, R3) were found walking outside the parking lot of the assisted living front doors when they were able to open the memory care side door without the alarm sounding due to a faulty delayed egress system. A third party alerted staff who escorted them back to the memory care unit. Staff notified R2 & R3’s responsible parties, Community Care Licensing (CCL) and Ombudsman of the incidents. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure reporting requirements are being followed is unsubstantiated. Allegation: Licensee does not ensure staff are trained in emergency evacuation procedures Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ED, DHS, WCD) who stated that the facility’s Emergency Disaster plan for the Elderly is reviewed and discussed monthly in staff meetings with assignments executed during an emergency evacuation – Environmental Director (EVD) to direct evacuation & person count, Director of Health Services (DHS) to handle first aid, Memory Care Director (MCD) to supply updated telephone emergency numbers, Wellness Program Director (WCD) to coordinate transportation & rally points, Business office manager (BOM) to notify responsible parties of any emergency evacuation and Executive Director to notify Community Care Licensing and other agencies. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that Licensee does not ensure staff are trained in emergency evacuation procedures is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Licensee does not ensure fire evacuation drills are conducted quarterly Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ED, DHS, S2, S3) who stated that fire and earthquake evacuation drills are conducted quarterly with written documentation kept for reference. Annual fire inspections were also conducted with the local fire department staff in addressing any issues with regards to fire safety and equipment. LPA reviewed quarterly fire evacuation drill records completed in 2023 and 2024. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not communicate with resident’s responsible party is unsubstantiated. Allegation: Staff do not ensure resident is accorded personal privacy Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (S2, S3, S4) who stated that they treat each resident with dignity and respect. They conduct status checks on each shift to ensure each resident’s needs are met such as diaper changes, toileting, dressing, grooming, transfers, bathing and personal hygiene. They denied violating residents’ privacy. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not ensure resident is accorded personal privacy is unsubstantiated. Exit interview conducted and a copy of this report provided.