complaint·March 27, 2025

Continued from LIC 9099 LPAs also conducted resident and staff interviews between 10:00 A.M, and 3:00 P.M. Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined: Regarding allegation “Staff do not ensure entrance door is in good repair” it was alleged that the main front door is broken and does not open and close correctly and residents using mobility devices such as wheelchairs and scooters have trouble going in and out of the facility. LPAs conducted interviews with residents including those who rely on electric scooters and wheelchairs as well as ambulatory residents. Residents who do not use mobility devices reported that the door closes quickly, and, on occasion, slams shut. Those using mobility devices stated that entering and exiting the facility is extremely difficult due to the door’s weight explaining that to exit, residents must push the door open using their scooters or wheelchairs while re-entering requires significant effort, often leading to struggles in maneuvering through the doorway without getting caught between the door and the frame. In many instances, residents must rely on the receptionist for assistance in opening the door. Several residents suggested ADA-compliant automatic system as a solution. Additionally, LPAs observed that the main entrance door is not properly maintained by having a missing safety spring door closer, which causes the door to close without control behind individuals as they enter and/or exit. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “Staff do not ensure entrance door is in good repair” therefore, the allegation is deemed SUBSTANTIATED at this time. Regarding allegation “Staff do not ensure residents are spoken to in an appropriate manner” it was alleged that management and caregivers are being hostile toward residents. Administrator stated that residents have not reported instances of caregivers being rude or yelling. Interviews with staff revealed that they are unaware of occasions where residents have felt disrespected. Some caregivers reported that in certain cases, they have experienced disrespectful behavior from residents. However, during interviews conducted by LPA Conway, eight (8) out of fourteen (14) residents expressed concerns that the Administrator and caregivers are unfriendly and sometimes speak to them in an aggressive manner. Continued on LIC 9099-C Continued from LIC 9099-C Residents stated they have felt disrespected by staff or witnessed staff be rude or mean to other residents. Others felt that their concerns were ignored by the Administrator or that raising complaints would not lead to any meaningful changes. Some residents reported being afraid to bring up facility-related issues due to perceived threats of eviction or disciplinary action. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “Staff do not ensure residents are spoken to in an appropriate manner” therefore, the allegation is deemed SUBSTANTIATED at this time. Regarding allegation “Facility does not ensure sufficient night staff is on duty for residents in care”. It was alleged that caregiver(s) exited the facility during the NOC shift (Nocturnal-10pm-6am), potentially leaving residents unattended. Administrator stated that the NOC shift in Assisted Living and Memory Care normally consists of 2 caregivers. Additionally, Administrator indicated that no complaints have been received regarding NOC caregivers leaving the facility during their shifts. To support that statement, Administrator provided documentation where caregivers manually write their names and their signature every 30 minutes after completing a walk-through of the facility. LPA Conway reviewed and compared the facility’s sign-in sheets, timecards and caregiver’s schedule from 07/13/2024 through 07/23/2024. During this review LPA discovered that Staff #1 (S#1) on 7/17/2024, Staff #2 (S2) on 7/18/2024, and Staff #3 (S3) on 7/20/2024 were documented as working on the walk-through sheet, however, a review of timecards and schedules confirmed that S1, S2 and S3 did not work on those dates. LPA requested video footage, however, on 07/23/24 the Administrator stated that cameras are not in working conditions at the time. Interviews conducted with staff reported concerns regarding the NOC shift caregivers leaving the facility and sleeping in their cars while on duty. Additionally, residents interview revealed that the number of caregivers available during the NOC shift is not sufficient to meet residents’ need in a timely manner. Reporting that wait times range between 45 minutes to an hour, and that residents with urinary incontinence are not checked or changed during the late-night hours. Continued on LIC 9099-C Continued from LIC 9099 Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted additional telephonic interviews with credible witnesses and other relevant parties. The following was then determined: Regarding allegation “Staff do not ensure residents special dietary plan is being followed”. It was alleged by Resident #2 (R2), that staff are not following their special dietary restriction, requiring them to use their own money to purchase food. Interview with Administrator revealed that the facility accommodates multiple residents with prescribed modified diets. Clarifying that for cognitively capable resident who can make independent decisions, the facility provides a variety of menu items and suitable substitutes that align with their dietary restrictions or needs. However, for residents with dementia, the facility cook prepares meals that comply with their prescribed dietary plans. Furthermore, Administrator explained that the facility offers three (3) meals a day and snacks to all residents in care. Also, they stated that residents who are able to leave the facility unsupervised have the right to purchase outside food at their own discretion. However, the facility is not responsible for monitoring whether those food choices align with their prescribed diet. Interviews with staff revealed that the kitchen maintains a list of residents with dietary restrictions, which is accessible to caregivers to ensure awareness. Staff also noted that residents have the right to choose meals that may not follow their prescribed diet. In such cases, caregivers may suggest alternative meal options, but ultimately, residents retain the right to make their own food choices, including additional servings. Resident interviews further confirmed that the facility offers a menu with a variety of meal options, and if a meal does not fit a resident’s dietary needs, a substitute dish or salad is offered as an alternative. During the course of the investigation, the LPA obtained copies of the facility’s menu and alternative menu, as well as R2’s physician’s report (LIC 602) and care plan. These documents confirm that R2, a cognitive capable Assisted Living (AL) resident, has a special diet but is able to self-manage their dietary needs and feed themselves. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred. Therefore, the allegation “Staff do not ensure residents special dietary plan is being followed” is deemed UNSUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation “Facility does not ensure staff have ability to communicate with residents”. It was alleged that several staff don’t speak or understand English. Information gathered during the course of the investigation reflected that some caregivers, servers and housekeeping staff have limited English proficiency. LPA interviewed 17 residents, 13 residents did not speak Spanish, 2 were bilingual and 2 spoke only Spanish. According to fourteen (14) out of seventeen (17) residents interviewed stated that they had no concerns communicating with staff. Those residents who do not speak Spanish acknowledged that communication with some staff can be challenging at times due to language barriers. However, they adapt by using hand gestures, point at objects, or using phone translation apps to facilitate understanding. LPA conducted interviews with seven (7) staff members. Two (2) out of seven (7) staff members stated that their English is limited and preferred to be interviewed in Spanish. Spanish-speaking staff confirmed that if they have any questions or need clarification, they seek assistance from other caregivers to ensure residents’ needs are met. Despite some staff having basic English skills, any concerns or issues can be promptly addressed by other caregivers, Med-Tech or the Administrator as needed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Facility does not ensure staff have ability to communicate with residents” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. Continued on LIC 9099-C Further concerns were raised by Resident #1 (R1), an independent resident able to leave facility unsupervised. R1 explained that for security reasons, the main door is locked after hours and can only be opened by caregivers. R1 reported an incident where upon returning from an outing around midnight, they had to wait approximately 35 minutes outside before a caregiver unlocked the door to allow them entry. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “Facility does not ensure sufficient night staff is on duty for residents in care”. Therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.