Complaint·May 7, 2024

Investigation revealed the following: Regarding allegation, Staff did not follow proper reporting requirements , it is alleged that R1 did not return to the facility on 03/27/24 and that facility administrator filed a missing person report with local law enforcement but did not report the incident to Community Care Licensing Division (CCLD). Administrator allegedly stated that the incident was not reported to CCLD because R1 did not sign an admission agreement and was not considered a resident due to that. Interview conducted with Administrator Rempel revealed that R1 was admitted to the facility on 02/13/24. She denied ever saying that R1 was not a resident of the facility. She stated that R1 would go out for daily morning walks. She stated that R1 went out on 03/17/24, and did not return to the facility. On 03/18/24, Administrator filed a missing person report with Los Angeles Police Department (LAPD) and also created and sent in an unusual incident report to CCLD within 7 days per regulation. She stated that she also called and made a report to Veterans Affairs (VA) Placement Coordinator. Interview conducted with facility administrator revealed that she always makes appropriate reports to all applicable agencies when needed. She stated that she is aware of reporting requirements for all government and local state and county agencies that the facility is affiliated with. Interviews conducted with facility staff revealed that they are properly trained on how to properly report incidents to all applicable agencies when needed. Interviews conducted with facility staff revealed that facility staff create and submit unusual incident reports to CCL within 7 days, and facility staff keep family members, responsible parties and conservators (if any) notified of any incidents involving residents. LPA review of documents revealed that the facility completed and submitted an incident report to CCLD in a timely manner as well as notified responsible party of incident(s) involving R1. Unusual Incident/ Injury Report reviewed was dated 03/18/24. R1's admission agreement was signed and dated on 02/13/24. LPA also observed/ reviewed LAPD Missing Person report dated 03/18/24. LPA additionally spoke with VA Placement Coordinator Mona LeDuc who stated that the facility did call her to report that R1 was missing from the facility. She stated that the facility is very good at keeping the VA informed of any incidents involving resident's receiving services from the VA that are residing at the facility. Interviews with 6 out of 7 residents revealed that facility maintains documentation and when necessary family or responsible parties are notified of incidents and they do not have any concerns regarding facility's documentation. Based on statements gathered from interviews conducted with staff, VA Placement Coordinator, residents and LPA review of records there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff did not safeguard residents' personal property, it is alleged that on 04/30/24, R2 reported that two gold coins were stolen from their room and that R2 suspects that S4 took them as the staff goes into R2’s room without permission. Additional personal items that were stored in the facility garage were also reported missing by R2. It is also alleged that on 04/29/24, R3 reported that their California Identification Card and their Veteran ID card were stolen from their bedroom dresser the week of 04/22/24. Administrator stated that if a resident reports that they have any missing belongings including any money they will document and investigate all alleged theft and loss of personal property. Staff will be responsible for searching for missing items and if items cannot be found, an estimate of the value will be assessed. If the theft amount exceeds $100.00, a report will be filed with appropriate law enforcement agency. Interview with Administrator Rempel and facility staff revealed that facility staff do not take any resident belongings. She stated that staff do not go in to resident rooms and take their belongings even when they are hospitalized or out of their rooms. Administrator stated that R2 did report that they were missing three gold coins and that S4 took them as S4 goes into their room. She stated that S4 is a housekeeper and does go into resident rooms to clean. Administrator stated that gold coins are not listed on R2's Personal Property and Clothing Record and that staff did attempt to help R2 locate their missing items but none were found. Administrator stated that R2 showed her a picture of the coins but she never physically saw them. Staff stated that R2 can be aggressive and repeatedly makes false allegations about staff. S1-4 deny ever taking any items from resident rooms. S3-4 stated that they do go into resident rooms but only conduct housekeeping services and they do not touch resident's personal items or open their personal drawers. Administrator stated that R2 could not indicate what items were missing from the garage and only reported the coins missing. Administrator stated that she was not aware that R3 reported that their CA ID or VA ID were missing. Staff interviewed denied ever taking any residents personal items such as money, coins or IDs. S3 stated that they pick up any loose change found on the floor while they are cleaning and will place on top of resident's drawers. Interviews conducted with 6 out of 7 residents revealed that facility staff respect their belongings and have never taken any of their belongings. 6 out of 7 residents stated that staff always knock before coming into their rooms. 6 out of 7 residents stated that they are satisfied with all the services they get at the facility and stated that they do not have any concerns, and staff are very helpful and always assist them when they need assistance. R2 stated that they could not recall what was missing from the property they have stored in the garage but that they know stuff is missing as they heard a resident talk about a 2011 concert that they attended. R3 stated that they located their CA and VA IDs and that they had just misplaced them in their room. LPA observed staff knocking and announcing themselves before going into resident rooms. LPA reviewed R2's Personal Property and Clothing Record and did not observe that gold coins were listed. LPA also observed R3's CA and VA IDs in their possession. Based on LPAs observations, review of records and statements gathered from interviews conducted with staff and residents there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held. A copy of the report was provided to Administrator Anna Rempel.