complaint·May 2, 2023

During the visit on 3/24/2023, a physical tour of the facility was conducted, LPA interviewed Executive Director Barbara Tyler, Staff (S4-S7), Residents (R2- R7), and a family member (R11). Medications for R2 and R8-R10 were reviewed. File review was conducted for R1, and former Staff members (S1-S3). LPA obtained the staff roster, resident roster, S1 disciplinary actions, and R1’s family member's correspondence with the facility. LPA attempted to contact former staff members (S1-S3) and left a voice mail. LPA interviewed S1 after the visit was completed. The investigation reveals the following: Regarding “Staff members spoke inappropriately to the resident.” It is alleged that S1 was unprofessional and inappropriate to residents. The interview with the Executive Director confirmed that some residents thought S1 was rude. The Executive Director further stated that S1 may have been stressed due to working a lot of hours during that time. 2 out of 4 staff expressed that S1 and S2 was aggressive with residents. 1 out of 4 Staff stated S1 worked a lot and seemed to be stretched thin. 1 out of 4 staff did not work with S1 but commented that staff does not treat the residents inappropriately. 4 out of 6 residents do not remember S1. 1 out of 6 of residents stated S1 was rough when providing showers. 1 out of 6 residents never met S1 but commented that the staff is friendly. During the interview, S1 denied the allegation. LPA reviewed S1’s file and observed S1 received three (3) corrective actions from the facility for inappropriate acts towards a resident or failing to provide appropriate care to residents. S1’s disciplinary actions led to S1’s termination. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview Conducted with Denise Bartley and Christina Schoech / Appeal Rights / A Copy of the report was emailed to the facility During the visit on 3/24/2023, a physical tour of the facility was conducted, LPA interviewed Executive Director Barbara Tyler, Staff (S4-S7), Residents (R2- R7), and a family member (R11). Medications for R2 and R8-R10 were reviewed. File review was conducted for R1, and former Staff members (S1-S3). LPA obtained the staff roster, resident roster, S1 disciplinary actions, and R1’s family member's correspondence with the facility. LPA attempted to contact former staff members (S1-S3) and left a voice mail. LPA interviewed S1 after the visit was completed. The investigation reveals the following: Regarding “Staff failed to meet the resident’s hygiene needs.” It is alleged that S1 was chastising R1 for frequent diaper changes. The interview with the Executive Director and staff concluded with everyone denying the allegation, stating that they have not received any complaints from residents regarding the issue. They also expressed that the facility has always taken care of the resident’s hygiene needs. 3 out of 6 residents stated that they are independent and do not need assistance. 3 out of 6 residents stated the facility takes care of their hygiene needs. The investigation reveals the following: Regarding “Staff failed to give resident medication timely.” It is alleged that medications were provided two (2) hours late. The interview with the Executive Director and staff concluded with everyone denying the allegation, stating that the facility administers residents’ medications on time. 2 out of 6 residents expressed that they are independent and do not need assistance with their medications. 1 out of 6 of residents expressed that they do not take medications. 3 out of 6 residents stated the facility has always given them their medications timely. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Denise Bartley and Christina Schoech and a copy of this record was emailed to the facility.