Office review·January 25, 2023

Licensing Program Analyst(s) (LPA) Mary Flores and Licensing Program Manager (LPM) Tony Vasallo conducted an Informal Office meeting at the regional office with Virginia Garcia Administrator. During the meeting the following was discussed: The purpose of the meeting was explained to the administrator Virginia Garcia. LPA Flores provided findings for complaint #28-AS-20210303163807. Findings regarding allegation resident #1(R1) sustained a fracture while in care were substantiated as there was enough evidence during interviews conducted and records reviewed. Additional staffing to ensure sufficient staffing for each shift. When hiring staff through registry facility is to ensure staff is properly trained to perform duties. Facility provides training to staff in English/Spanish. Additional deficiency is noted during this visit related to complaint investigation where it was revealed that staff #2(S2) was discovered using Resident #1's (R1) private bathroom. On 2/23/21 R1's responsible party visited R1 upon walking into the room found R1 sitting in a chair and S2 exiting R1's bathroom pulling him/her pants up. S2 confirmed he/she used R1's bathroom and it was not unusual for staff to use the resident's bathrooms. S2 had been provided two disciplinary notices prior to the incident. Disciplinary notice dated: 2/21/20 notes S2 used another resident's bathroom to shower another resident. Disciplinary notice dated: 7/13/20 notes S2 yelled at another staff who was attempting to assist S2 with resident care. S2 reassigned to the position as a caregiver after the incident. Plan of correction for deficiencies were discussed with Administrator. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Virginia Garcia Administrator and a copy of this report, LIC 809D, and appeal rights were provided.