complaint·March 26, 2025

It was alleged that some residential rooms have the top door closer of their entry door off. LPA interviewed Administrator and ED who stated that all resident apartments in assisted living (AL) and independent living (IL) have the same doors. ED stated that some residents have asked to loosen the door closer hinges or take them off because the door is heavy, but they are not allowed to since they are fire doors and need to automatically close. One (1) out of seven (7) staff confirmed that the maintenance team will sometimes loosen the door closer or disconnect them per resident request if their door is too heavy or they require ambulatory assistance devices, such as walkers or wheelchairs. Between 01:02PM-01:11PM, LPA observed three (3) doors in the IL building A on the third, fourth, and sixth floors. Two (2) out of three (3) doors observed did not have a functional door closer; one door closer was observed to not fully close the door at 01:06PM and the other door closer was observed disconnected at 01:11PM, resulting in the door staying open. Maintenance staff was immediately notified to repair the door closers, and staff will get trained to deny the request about removing or loosening door closers as they are required for fire safety. The two (2) door closers were repaired during LPA’s visit. Administrator stated that staff will audit all resident doors and repair any door closers as needed. Based on observation and interviews, the allegation “Staff does not ensure resident's door is in good repair” is deemed SUBSTANTIATED at this time. 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. It was alleged that a resident’s medications were found in their wheelchair multiple times. There was also a concern about residents getting their medications administered. LPA conducted a medication review between 03:54PM-04:20PM for three (3) residents of which one (1) is independent living (IL) and one (1) is assisted living (AL). Medications are centrally stored and locked in the wellness offices. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. Medications are prepared for each shift and are not prepared for more than 24 hours in advance. No errors observed during the medication review. Staff interviewed were knowledgeable in medication administration, storage, and documentation and knew procedures for medication destruction and administration errors. No concerns were noted. Interviews conducted did not have supporting evidence of the allegation. Based on record review, interviews, and medication review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff does not ensure resident's medication is being administered” is deemed UNSUBSTANTIATED at this time. It further was alleged that Resident #1 (R1) leaves the facility unassisted but is not capable of doing so. LPA reviewed R1’s assessment completed by the facility on 09/12/2023 which documents R1 as “does not require assistance with escorting.” However, R1’s physician’s report dated 09/15/2023 documents R1 with a dementia diagnosis, confused/disoriented mental condition, and unable to leave the facility unassisted. R1’s newer assessment completed by the facility on 04/15/2024 documents that R1 “requires escorting and/or physical assistance to attend meals and daily events.” LPA interviewed ED, Administrator, and R1’s responsible party who all confirmed that R1 has a private companion six (6) days a week and does not leave the facility unassisted. R1’s responsible party did not express concerns about R1’s amount of supervision or risk of wandering. Based on record review and interviews, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff does not provide adequate supervision resulting in resident wandering away from facility” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C. Lastly, it was alleged that residents in independent living (IL) do not get three (3) meals a day provided to them. LPA reviewed three (3) admission agreements for IL, assisted living (AL), and memory care (MC). The IL admission agreement states that “Independent Living residents will receive a monthly Flexible Spending Account that can be used toward a limited meal plan that includes snacks and our daily menu that is priced a la carte.” Food service is paid via a point system. IL residents are allotted 800 points per month where one (1) point is equivalent to $1. IL residents can choose to spend their 800 points however they wish, including for their visitors. The 800 points covers about two (2) meals a day as breakfast is typically $9 and a full lunch/dinner is $13. More points can be used depending on the entrée, for example, a filet mignon entrée will be more than the typical 13-point dinner, and on drinks like smoothies or coffee. Admission agreements do not specify the amount of points residents have in their monthly allowance, however, receipts provided for meals state the resident’s total allowance, usage, and remaining balance of points for that month. Residents can also request itemized monthly bills. IL residents were notified of their $800 meal allowance through a weekly update delivered to resident apartments on 07/21/2024 stating “DINING UPDATE: This is a friendly reminder that the dining credit for all IL residents will change to $800 starting the August rotation. This dining credit allowance meets the contractual requirement for two (2) four course meals for each IL resident.” AL residents get an allowance of 1050 points per month, which is about three (3) meals a day. LPA reviewed Appendix M of the AL admission agreement which states that “three meals a day in the dining areas or delivered by room services” are “included in the monthly rent” for “assisted living services.” AL residents were notified of the point system via a letter stating “Starting October 1 st [2024], you will receive a monthly dining dollar credit of $1050.00. This credit can be used to purchase any of our dining options…” LPA also reviewed Appendix M of the MC admission agreement which states “three meals a day and snacks” are “included in the monthly rent” for “memory care services.” Five (5) out of five (5) residents interviewed expressed no concerns of food services and felt that the amount of food provided is adequate and taste/quality are no concern. LPA observed residents dining in the Warner’s dining hall at 12:17PM and observed adequate food service. Based on record review, interviews, and observation, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff does not provide adequate food service” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.