complaint·November 3, 2023

The investigation revealed of the following: Allegation#1 "Staff stole resident's belongings" LPA interviewed 14 residents and 14 out of 14 denied the allegation and reported staff never stole their belongings. 12 residents out of 14 residents stated that they never lost anything in the facility. LPA interviewed staff and stated that no residents ever complained the staff stole their belongings and they did complete LIC621 when residents first moved into the facility. Allegation#2 " Staff did not change resident's urine soaked bedding." LPA interviewed 14 residents, 12 out of 14 residents and denied the allegation and stated that the staff cleaned their room every day and changed their beddings every week or as needed. LPA interviewed the staff and denied the allegation and reported they changed and checked on the incontinence residents every two hours. Staff stated that they changed R1's beddings everyday or as often as needed. Staff reported R1 refused to be changed most of the time and caused soaked bedding but they would let housekeeping know immediately if they observed R1's bedding was soaked in wet. LPA toured residents' rooms in the facility and all the beddings and linens are clean. Allegation#3 " Staff did not ensure that fall risk measures were in place for the resident at the facility." The administrator and LVN stated that although R1 is considered a fall risk resident, she is not a high risk for falls. She did not fall a lot and did not have any fall incidents lately. LPA also reviewed R1's incident reports and did not observe any fall incident for R1 in the past month. Administrator also reported their house doctor usually comes once a month and see R1 and the doctor knows R1 very well and they never recommended or suggested a hospital bed with bed side rail for R1 due to R1's condition. Based on the documents reviewed, interviews conducted with staff and residents, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted with Priscilla Gaytan Administrator and a copy of this report was provided. The investigation revealed of the following: Allegation " Facility is odoriferous." LPA toured R1's room in Room#19 from the memory care unit and when LPA stepped into R1's room, the room was immediately an overwhelming smell of both urine and mildew. According to the administrator and staff, its reported R1 requires total assistance from staff and R1 always refused to change and therefore the beddings were always soaked but staff did change R1's bedding at least once a day or as often as needed. Housekeeper indicated that they would open the window and spray the air refresher to prevent the smell of urine in R1's room. Based on LPA's observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D. An exit interview was conducted with Administrator Priscilla Gaytan and a copy of the report and appeal rights were provided.