complaint·May 4, 2022

(continued pg2) -Regarding allegation: Facility is not properly secured. On 3/22/22 LPA reviewed the camera footage and observed that on 3/17/22 approximately 8:35am there wasn’t a staff at the front desk, nor was there staff around the area to supervise that dementia residents do not wander outside unsupervised. On 3/22/22 LPA interviewed administrator, Susana Fuentes and asked if there are auditory devices to notify staff when someone walks through the backdoor. Susana states that the facility is not a locked facility, and there are no alarms, however facility has an auditory device on exits. There’s a box located at the front desk, and when the backdoor is opened it will make a sound to notify staff. Staff will then review the camera to ensure its not a resident with dementia attempting to exit unassisted. On 3/22/22 at approximately 1:06pm LPA asked Susana to test the backdoor auditory devices, S1 opened the backdoor, however there was no alarm heard at the front desk. On 5/4/22 at approximately 9:31am LPA observed resident walk out the backdoor and LPA didn’t hear an auditory alarm go off to notify backdoor was opened. LPA asked S1 about the auditory device, in which she replied; the backdoor was replaced recently and the alarm was disabled. Facility is working to get the auditory device to work. Based on LPA’s interviews, and record review(s), the preponderance of evidence standard has been met, therefore the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Exit interview conducted and a copy of this report and appeal rights provided to facility representative. -Regarding allegation: Resident wandered from the facility. Per Unusual incident report (UIR) dated 3/17/22; on 3/17/22 an outside pedestrian came to notify facility that resident was walking outside and was requesting to go to Torrance. S2 went out to check and determined that it was R2. Per Physician report R2 is diagnosed with Dementia and requires supervision to leave facility. Per Preplacement Appraisal dated 3/4/13 R1 has no sundowning, aggression, nor wandering behaviors. A reappraisal was not available at time of visit. On 3/22/22 LPA Cardenas reviewed the camera footage and observed that on 3/17/22 R2 walked out of the facility front entrance unassisted by a staff at approximately 8:35AM and was assisted back to the facility by staff at 9:03AM. told that the maintenance man would be notified, however the heater was not adjusted and the bedroom was 68 degrees. In addition, during a conversation with R3 it was brought up that administrator Susana didn’t allow R3 to install a television in the bedroom because a tv was already in that bedroom. -Regarding allegation: Resident was spoken to in an inappropriate manner. On 3/22/22 LPA Cardenas interviewed R1-R7, of those interviewed five (5) indicated that staff do not speak to them in an inappropriate manner. R7 indicates facility is fine and refused to continue the interview. On On 3/22/22 LPA interviewed S1 who indicates that none of the residents have complained that staff are speaking to them inappropriately. Nor that none of the staff have reported witnessing other staff speak inappropriately to resident. S1 denies speaking inappropriately to a resident. -Regarding allegation: Resident's request for heat in their room was denied. On 3/22/22 LPA interviewed S1 who indicates that thermometer temperature is automatically regulated. There are residents that feel facility is too cold, others feel its too hot, therefore temperature is kept in between to accommodate everyone. Temperature varies throughout the facility. S1 states that two weeks ago, a resident complained that their bedroom was too cold so S4 was asked to adjust temperature. On 3/22/22 LPA Cardenas interviewed S4 who indicates that one resident prefers room to be on the warmer side. A few days ago the thermometer read 78 degrees F and the resident complained that it was cold. Temperature is usually adjusted as needed per request; however other residents need to also be taken into consideration. On 3/22/22 LPA interviewed R1-R7, four (4) resident indicated that room is comfortable temperature and requests are responded appropriately. R2 states it was cold in the room once because a window was left open. R7 indicates facility is fine and refused to continue the interview. On 3/22/22 LPA Cardenas toured the facility in the AM and PM and noted temperature on the first and second floor (mid-points). LPA observed temperature was within title 22 regulations. On 5/4/22 LPA toured the facility in the AM and observed temperature was within title 22 regulations. -Regarding allegation: Resident was not allowed to install a television in their room. On 3/22/22 LPA interviewed R1-R7. R3-R6 indicates that they are allowed to bring furnishings of their choice to their bedroom. R3 also confirmed being allowed to install a television in the bedroom. However, it took a few days because the wifi needed to be hooked up. R7 indicates facility is fine and refused to continue the interview. On 3/22/22 LPA Cardenas interviewed administrator, Susana who indicates that resident bedrooms are furnished upon mo “Although the allegation may have happened or is valid, there is ving in. However, residents are allowed to bring in any furnishing of their choice. They can decorate the walls with pictures to their liking. Facility generally won’t provide a tv, but if residents need a tv facility has donations that residents can have. not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.” Exit interview conducted and a copy of this report was provided to facility representative.