complaint·July 25, 2023

The investigation revealed the following: Regarding the allegation: " Staff are not following resident's care plan. ” Six (6) out of seven (7) resident interviews have denied this allegation. All six (6) staff interviews have denied the allegation. LPA's observation and the facility’s internal records indicate that there are monthly logs being conducted and followed. Although the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation did, or did not, occur. Therefore the allegation is "Unsubstantiated" . Regarding the allegation: " Staff does not respond to resident's calls for assistance in a timely manner, or not at all." Four (4) out of seven (7) resident interviews have denied this allegation, while two (2) resident interviews have noted indifference at the wait in response time. All six (6) staff interviews have denied the allegation and all six (6) concur that there is a one-minute electrical response in which staff must use a special key around their neck to turn off the electrical alarm. LPA has also observed all staff wearing a pager and two-way radio for immediate communication. Although the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation did, or did not, occur. Therefore the allegation is "Unsubstantiated" . The investigation revealed the following: Regarding the allegation: "Facility does not have sufficient staff to meet the needs of the residents." All seven (7) resident interviews have agreed with the above allegation, while three (3) out of six (6) staff interviews agree with the above allegation. LPA has reviewed documentation which notes that the last permanent transportation driver moved positions as of 04/27/23 while the last long-term executive director worked as of 04/29/23 and lastly the health and wellness director and coordinator on 07/07/23 and 07/20/23, respectively, which left the organization unstable. There has been stand-in executive directors and health and wellness director, supporting the community in the meantime and will continue to support the community until a permanent health and wellness director will begin training on 7/31/23. In addition, 8 hours per shift for care giving will be available 08/01/23. LPA has observed advertisements for the various positions listed, yet these positions have been vacant for a time and criminal clearances must be obtained prior to staff working on-site. Based on interviews, record reviews and observations conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. Regarding the allegation: "Staff are not adequately communicating with residents regarding updated information." Five (5) out of seven (7) resident interviews have agreed with the above allegation, while two (2) out of six (6) staff interviews agree with the above allegation. Interviews indicate that lack of direction from executive staff led to the facilities’ inability to follow through at providing an updated illness status to residents. Based on interviews, record reviews and observations conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. On 07/25/23, an exit interview was conducted and plans of corrections were developed with Dimple Kamdar, Operations Specialist. A copy of this report and appeal rights have been provided. On 01/31/24, an exit interview was conducted with Mia Nakamatzu, Executive Director. A copy of this report and appeal rights have been provided.