complaint·September 26, 2023

General state of the building. Resident rooms were in good repair and the floors were clean. LPA interviewed staff regarding the procedure to clean dirty rooms. Each room is on a schedule to be cleaned once a week. When a spill occurs, housekeeping is contacted to address the issue. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. LPA reviewed documents detailing various incidents R1 was involved in. Facility notified CCLD as required but did not notify the local Ombudsman office of all of the physical assaults due to sending the information to a wrong fax number. The fax number has been corrected. Based on records reviewed LPA observed the facility did not notify the responsible person of each incident. LPA discussed the lack of notifications with the Executive Director and provided a copy of the reporting requirements regulation. Based on interviews conducted, R1 was in possession of a lighter. LPA interviewed staff and was informed the lighter is typically stored in the medication room. Staff removed the lighter from R1's possession. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Charmin Bailey and Appeal rights were given.