complaint·February 20, 2025

Information obtained confirms that required documents were provided to the facility, such as the resident’s physician’s report and medication list, and that ED Owens spoke with R1’s doctor to create a plan of care. LPA reviewed R1’s file retained at the facility and observed R1’s physician’s report dated 01/17/2024, TB test dated 07/20/2024, COVID/influenza A + B/multiplex NAA nasal test from 07/18/2024, hospital discharge paperwork from 07/18/2024 – 07/20/2024, R1’s medication list dated 07/20/2024, and interim service plans from the facility dated 07/20/2024 and 07/23/2024. R1 moved into the facility on 07/20/2024, however, no admission agreement was provided for review or signature even after prompting from responsible party. No admission agreement, pre-placement appraisal, or care plan/needs and services appraisal was observed in R1’s file. R1 resided at the facility for five (5) days without a contract between 07/20/2024 – 07/25/2024. ED Owens resigned without proper notice end of day on 07/22/2024. R1’s responsible party was informed by corporate management on 07/25/2024 that R1 needs to leave the facility as there is no written contract for R1’s admission. LPA interviewed Staff #1 (S1) and Staff #2 (S2) who were employed during the ED abandonment and confirmed that a resident was improperly admitted to the facility by ED Owens during that time. LPA interviewed current ED Weisbarth, HSD Nunez, and Resident Care Coordinator (RCC) Angelica Caton who were not employed at the facility during the time of the alleged incident. No concerns of the facility’s current admission procedures were noted. Interviews revealed that residents admitted during previous management were not properly assessed, however, the facility has been assessing residents and updating care plans quarterly and organizing resident files to be in compliance. Residents interviewed did not have evidence relevant to the investigation. LPA conducted previous visits regarding ED Owens and absence of management which were assessed during that time. Based on the facility’s history, interviews, and record review, the allegation “staff retained resident without proper admission procedures” is deemed SUBSTANTIATED at this time. Plan of Correction has been met as current administration is knowledgeable in admission procedures and is properly documenting admissions and assessing residents. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. Appeal rights and a copy of the report was provided.