complaint·March 21, 2022

Allegation: Facility has inadequate staffing: The complainant reported that facility is not providing enough care for dementia residents as well as other residents. Facility is admitting more dementia residents and the problems increase because they are using the Activity Room (1 st floor) as a day care center; and, there’s an average of 10 – 14 residents and one (1) staff member watching them. LPA/RA Ceniceros spoke to Administrator Fuentes who replied, in the past, whenever the facility was going to be short staff, they would contract with a health care staffing agency to fill the vacancy on a temporary basis - until a new staff member is hired on board. Recently, the facility hired three (3) additional staff members: caregiver, housekeeper, and an activities coordinator. LPA/RA interviewed seven (7) residents; and, the majority agreed that the facility has adequate staffing to meet his/her needs. LPA/RA interviewed six (6) staff members (S1-S6); and, the majority agreed that the facility has sufficient staffing to meet the needs of the residents. LPA/RA reviewed the facility’s residents’ roster, facility staff roster and staff work schedules (week of 11/28/21 thru 12/25/21 and current); and, the facility has sufficient staffing. Based on information gathered through interviews and observations and records review, the Department did not find sufficient evidence to support the allegation mentioned above. 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 . The investigation consisted of the following: LPA/RA Ceniceros interviewed Administrator, six (6) staff members (S1-S6) and seven (7) residents (R1-R7). During the course of this investigation, LPA/RA toured the facility’s activity rooms (located on the 1 st and 2 nd floors); reviewed facility records: staff roster, residents roster, activities calendars (December 2021 – March 2022); observed current posted monthly activity calendar (posted on the board by the main entrance) and residents participating in the A.M. and P.M. activities. Allegation: Facility does not provide activities for residents: The complaint alleges that the facility does not provide activities for residents. LPA/RA Ceniceros toured the activity room and observed (approx) 16 residents participating in the morning activity (exercise) at 10:35 a.m. and approximately 12 residents participating in the afternoon activity (music choice) at 1:20 p.m. (Report continued on LIC 9099C) LPA/RA Ceniceros observed the posted March 2022 Activity Calendar (photo) and reviewed past monthly activity calendars (December 2021 – March 2022). LPA/RA interviewed residents (R1-R7) regarding activities provided at the facility; and, the majority indicated that because of COVID some of their activities where stopped; however, now that COVID has been lifted, the facility is providing in-person activities; such as: arts & crafts, movie, bingo, board games, music choice, kareoke, and exercise; but, soon they’ll be doing outings into the community (i.e., park, shopping, theatre and/or restaurant). Based on information gathered through interviews and observations and records review, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is unsubstantiated . An exit interview was conducted and a copy of this report was provided to Administrator Susana Fuentes.