complaint·June 13, 2025

Allegation: Staff modified the resident’s medical device without authorization Investigation Finding: Substantiated During investigation, the department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1) & R1’s responsible party (POA) and reviewed resident's(R1) documents. ADM confirmed with LPA that R1's medical device was modified without her authorization to enable them to plug her medical device into the existing 2 prong ungrounded bedroom outlet. LPA observed all residents' bedroom outlets(Rms 1, 2, 3) had two prong ungrounded outlets. LPA observed only the kitchen area had grounded three prong electrical outlets. 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 modified the resident's medical device without authorization was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099-D. 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 do not ensure residents receive bathing services in a timely manner Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM, S1) and residents (R1, R2, R3). Residents (R1, R2, R3) confirmed with LPA that staff give them daily bed baths. R1 stated staff gives her a full shower every 7 days aside from getting bed baths. Staff confirmed with LPA that all non-ambulatory residents are given bed baths daily with R1 being given a full shower every Thursday. Staff denied not giving R1 a full bath over 13 days. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff do not ensure residents receive bathing services in a timely manner is unsubstantiated. Exit interview conducted and a copy of the report provided.