complaint·March 14, 2023

***This report serves as an amendment and supersedes the original complaint investigation report created on 06/23/22. The findings remain Unsubstantiated. *** LPA Tao also obtained R1’s Admission Agreement, R1’s assessment plan, Activities and Outings guidance (December 2020), L.A. County DPH Activity Protocol, Facility’s Activity Plan for Christmas special event, Dietary Protocol, Alternative Meal Delivery Procedure, Menus (November 29, 2020 - January 2, 2021), Activities Calendar (December 2020), resident#2 (R2)’s Assessment, R2’s Individualized Service Plan (IPP), R2’s Physician’s report, R2’s Move in Notification (6/2/20), R2’s personal rights, R2’s care plan, R2’s narrative charting, Dietary services (1/4/21) during facility’s COVID outbreak, DPH Outbreak Notification letter of COVID – 19 outbreak (12/16/20), and virtually toured the facility which included the kitchen, dining area, and activity room. Besides, LPA interviewed staff#1 (S1) and resident#1 (R1) over the phone. On 06/23/22, LPA/Retired Annuitant (RA) Elizabeth Ceniceros conducted a subsequent visit at the facility, reviewed resident files and delivered findings. LPA/RA obtained copies of staff roster and resident roster; and toured the facility’s commercial kitchen and dining room area. On 03/14/23, LPA Tao conducted another subsequent visit. During the visit, LPA obtained copies of staff and resident rosters, reviewed residents’ files, interviewed staff and residents, conducted a facility tour, and delivered findings. LPA interviewed staff from staff #2 (S2) through staff #6 (S6) and residents from resident#2 (R2) to resident#13 (R13). The investigation consisted of resident interviews, staff interviews, residents’ files review, facility tour, and LPA’s observation. In regard of allegation, “residents are not being provided activities”, it was alleged that staff did not provide social activities during COVID 19 lockdown of the facility. The investigation revealed the following: LPA interviewed resident, one (1) out of thirteen (13) residents said staff did not provide social activities during COVID lockdown. Twelve (12) out of thirteen (13) residents interviewed stated facility had provided activities to residents during lockdown. All staff interviewed denied the allegation. (- continued in LIC 9099 C-) ***This report serves as an amendment and supersedes the original complaint investigation report created on 06/23/22. The findings remain Unsubstantiated. *** Staff interviews and file reviews revealed the facility was going through lockdown due to COVID 19 outbreak occurred at the facility. Per LPA/RA Ceniceros’ investigation revealed that facility was following all state/county recommendations during the COVID-19 pandemic protocol. It included limiting the number of residents in social activities, facilitate social distancing, and outings. Residents were to limit their trips out of the community in accordance with local guidelines. Facility modified events to in-room activities/ games which caregivers provided activities to residents by going around each of the residents’ rooms and offering activities, such as Zen coloring, exercises, word search/sudoku, music/guitar playing, in-room games (Uno, dice games, cards), various room crafts, and movies. A review of the facility’s Activity Calendar (December 2020) showed facility had provided activities for the residents – including a holiday schedule of events on 11/12/20, 11/26/20, 12/10/20, 12/17/20, 12/18/20, 01/01/21. Facility had provided activities and still keep social distancing within the pandemic protocol. LPA Tao reviewed DPH Outbreak Notification letter, it stated facility had COVID – 19 outbreak on 12/16/20 which facility was lock-down and required to follow COVID -19 protocol on restricting social activities. During today’s visit, LPA observed residents had social activities at the facility. Therefore, there is not preponderance evidence to prove residents are not being provided activities. In regard of allegation, “staff are not providing adequate food service,” it was alleged that food comes to residents’ rooms in “to go” boxes and is cold. The investigation revealed the following: LPA interviewed resident#1(R1), resident revealed the food was cold when delivered to resident’s room. Twelve (12) out of thirteen (13) residents interviewed stated their meals were warm or not cold when the meal trays delivered to their rooms. All staff interviewed denied the allegation. Staff interviewed revealed facility had followed DPH’s COVID protocol on food services and staff did not receive complaints from residents regarding food was being served cold. Per LPA/RA Ceniceros’ investigation, it revealed that residents’ meal delivery was being served in “to-go” style which they were served in Styrofoam containers with plastic utensils, cups and paper napkins, to ensure food reaches the residents as hot as possible during COVID -19 lock down when the dining room was shut down for communal dining. Per record review, a special meal was provided on Christmas Day and residents had been notified prior to this holiday event which included Christmas caroling to the residents. A review of the facility’s menus was in compliance with food service. (- continued in LIC 9099 C-) ***This report serves as an amendment and supersedes the original complaint investigation report created on 06/23/22. The findings remain Unsubstantiated. *** As mentioned above, DPH Outbreak Notification letter stated facility had COVID – 19 outbreak on 12/16/20 which facility was lock-down and required to follow COVID -19 protocol on restricting communal dining. Per file review, facility had set up and followed Dietary Protocol, Alternative Meal Delivery Procedure, and dietary Menus during COVID lock-down period. On 12/28/20, a virtual tour of the facility’s physical plant was conducted including facility kitchen, dining room, and food pantry, they were observed to be in compliance. Therefore, staff were providing adequate food service. 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. An exit interview was conducted with Administrator. A hard copy of the reports were provided.