complaint·July 15, 2025

On 07/07/2025, LPA conducted a subsequent visit at 9:30AM. Beginning at 9:41AM, LPA reviewed and obtained additional documents and interviewed two (2) staff between 11:08AM and 11:40AM. At 11:23AM, the LPA and Front Office Receptionist conducted a tour of the facility. During today’s visit, the LPA and the ED toured the facility at 10:32AM to ensure there are no health and safety hazards. No immediate concerns were observed. The following was determined: Allegation: “Staff did not assist resident with care needs in a timely manner.” It was reported that Resident #1 (R1) did not receive showers or assistance with care needs when requested. R1 revealed that Staff refused to help with their wheelchair and claimed Witness #1 (W1) stated R1 can manage themselves independently. R1 also stated that Staff claimed R1 was not on the shower list when they requested a shower. W1 stated that R1 can complete tasks such as walking and wheeling themselves in their wheelchair, but did not instruct Staff not to assist R1. Interviews with seven (7) Staff confirmed that R1 frequently requested assistance but often changed their mind, and Staff did not report denying assistance. R1 is offered showers twice a week but commonly refuses them. Staff #1 (S1) explained that R1 requested to move their morning showers to the afternoon. After the adjustment was made, R1 then changed their preference back to the mornings, and Staff scheduled accordingly. S1 noted that Staff attempted to accommodate to R1’s needs, although R1 often contradicts themselves. Interviews with nine (9) residents indicated that Staff generally assist residents with their needs but can be slow to respond and fall behind on showers, depending on their current tasks. Resident #2 (R2) stated they had to shower without help once due to the Staff being occupied. Resident #3 (R3) reported missing scheduled showers because of staffing issues. According to Staff #2 (S2), all showers are required to be logged before the end of each shift, indicating whether the residents received or refused the offered shower. Refusals must also be reported internally. Agency Staff are also trained in this procedure, however S2 noted they fail to complete the logs. Report Continued on LIC 9099-C A record review of June 2025 showed inconsistencies in documentation for several residents. Residents #4 (R4) and Resident #5 (R5) did not have shower logs. Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8) were expected to have eight (8) showers documented but had three (3) entries each. Resident #9 (R9) had four (4) entries and Resident #10 (R10) had one (1) entry logged. The following residents were expected to have nine (9) documented entries in their shower logs: R3 had five (5) entries, R1 and Resident #11 (R11) each had four (4) entries. Additionally, Resident #12 (R12) had one (1) logged, Resident #13 (R13) had three (3) logged, and Resident #14 (R14) and Resident #15 (R15) each had six (6) entries logged. In the first week of July 2025, the shower logs also showed inconsistencies. No logs were documented for R6, R9, R15, and Resident #16 (R16). Resident #17 (R17), Resident #18 (R18), and Resident #19 (R19) were expected to have two (2) shower entries but had one (1) entry each. Furthermore, logs were created for R4, R5, and Resident #20 (R20), but no entries were documented for them during that period. The Resident’s Admission Agreement stated showers should be received twice a week, which is included in the basic services. The ED stated that all shower logs should be reviewed at the end of the day by Staff #3 (S3), however based on the LPA’s record review, it is not being done. The ED stated they would have a discussion with S3 regarding their duties. It was also stated that Agency Staff do not complete the logs despite receiving the training, and it is difficult to mandate it when they are typically assisting at the facility for the day. However, the facility’s Staff should know the requirements and their duties. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, 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 is cited (Refer to LIC9099-D). Exit interview conducted. A copy of the appeal rights and today’s report was reviewed and provided. On 07/07/2025, LPA conducted a subsequent visit at 9:30AM. Beginning at 9:41AM, LPA reviewed and obtained additional documents and interviewed two (2) staff between 11:08AM and 11:40AM. At 11:23AM, the LPA and Front Office Receptionist conducted a tour of the facility. During today’s visit, the LPA and the ED toured the facility at 10:32AM to ensure there are no health and safety hazards. No immediate concerns were observed. The following was determined: Allegations: “Staff did not allow resident to possess their personal belongings” and “Staff interfered with resident’s visit(s).” It was reported that Resident #1 (R1) was told by Staff and the Assistant Administrator (AA) that they were not allowed to have their personal belongings. It was alleged that the facility’s Staff and AA also accused R1 of being a “dirty hoarder” and informed R1 that they were not allowed to receive visitors due to this. LPA interviewed ten (10) residents and observed each resident had personal belongings in their units. Eight (8) out of ten (10) residents stated they have not experienced, or observed, Staff inform them or others that they cannot possess their personal belongings. R1 stated the AA informed them they will not be allowed visitors until they organize their belongings. Interview with Witness #1 (W1) revealed that the AA and Executive Director (ED) had not restricted their visitation to the facility. W1 chose to not visit R1 on their own accord and expressed they were in a tough situation regarding the ongoing issues of R1’s personal belongings. W1 expressed that they are more than happy to bring R1 any additional belongings they need, however W1 is aware that R1 already had too much in their room and had no space for more items. The facility’s Staff, the AA, and the ED have not communicated to W1 that they were not allowed to bring additional items. Resident #2 (R2) stated that when they first moved into the facility, the Staff told R2 that they needed to throw away a few of their items. R2 also stated that Staff threatened to throw away their belongings when R2 was out of the facility. Since then, R2 stated they have not experienced that treatment outside of that initial incident. Report Continued on LIC 9099-C Interview with ten (10) Staff revealed that residents have the right to their personal belongings as well as receiving visitors. Staff #1 (S1) stated residents can have visitors, but the facility must be notified of the visit. Additionally, S1 added that residents’ visitation can be restricted by their Responsible Party if they notify the facility of specific individuals who cannot have access to the resident. Staff #2 (S2) stated the visitor’s procedure should be to sign in/out at the office and afterwards the visitor can make their way to the resident’s unit. S2 specified that residents can receive visitors unless they are actively quarantining, then their visitation will be placed on a hold. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited for the above allegations. Exit interview conducted. A copy of today's report was reviewed and issued.