complaint·May 15, 2025

Continued from LIC9099 Staff left resident on the commode for an extended period of time During the course of the investigation, the Department interviewed residents and staff. Interview with R1 stated she placed on the commode for almost three hours. R1 stated she pressed the call button, no one came for hours. Interview with R2 indicated, when she presses the call button for assistance after using the commode, staff responds between five and ten minutes. Interviews with staff S1, S2 and S3 indicated residents who are nonverbal are checked on between five to ten minutes when on the commode. Residents who are verbal, will press the call button or call our names for assistance. S1 also stated during interview, S2 and R1 did not get along. S1 has been the mediator between the two of them over the telephone a couple of times. S2 stated she placed R1 on the commode and noticed another resident started walking towards the front door, thinking someone was ringing the doorbell, the ringing sound was coming from call button R1 pressed. Interview with S1 revealed, S1 reviewed surveillance recording and denied seeing anyone near the front door. Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . Health and Safety Code are being cited on the attached LIC809D. LPA already cited ( 87468.1 (a) (3) ) on complaint number (15-AS-20240806132429) Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D on complaint number (15-AS-20240806132429) . Failure to submit proof of correction (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 LIC9099A Staff mismanaged resident medication During the course of the investigation, LPA observed the medication in a locked cabinet, located in the kitchen. LPA reviewed residents R1, R3 and R5 physician’s reports and facility’s medication administration record (MAR). LPA observed medications were administered correctly. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.