complaint·September 17, 2021

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not provide adequate assistance to meet necessary medical needs of the resident. The details on this allegation state the facility did not allow for (R1) to have access to transportation for medical appointments. (R1) reports the staff is not allowing him access to transportation vehicles. On 07/13/21, the staff refused transportation assistance for his medical appointment. An interview with the administrator revealed (R1’s) in-house transportation was terminated on 07/12/21. The reason was due to personal conflicts between (R1) and (S3). The administrator took immediate action to de-escalate strife between the resident and staff by terminating (R1)’s in-house transportation services. A decision the administrator felt was necessary as it created an unstable environment for both parties involved and other residents transported to their daily appointments. An interview with (S3) revealed that (R1) was dissatisfied with his services and it created an uneasy work setting between the resident and staff. The administrator stated the (R1) had alternative transportation assistance with Access Services. However, (R1) claims the services are not reliable. According to the administrator, in-house transportation services resumed for (R1) on 08/13/21 after an alternative plan was put in place. Based on interviews and records reviews, there is sufficient evidence to support the allegation mentioned above had violated Title 22 regulations. Based on interviews that were conducted record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated . California Code of Regulations, Title 22, Division (6), and Chapter (8) are being cited on the attached LIC 9099-D. INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility staff transports residents in an unsafe manner. It is alleged that staff #3 (S3) is unsettling, throws tantrums, and drives dangerously. The Department conducted interviews with residents #2-#10 (R2-R10, staff #1-#10 (S1-S10) and witness #1 (W1) a review of (S3)’s personnel file and found there no evidence to support the allegation mentioned above. An interview with (S3) states his primary duties are to transport residents to medical/dental appointments and that secondary duties are operational tasks for management. (S3) reports that he has been an employee for two and half years and claims that he had no complaints about his services nor how his driving performance. (S3) claims that he has a clear record with no driving violations. (S3) reports he has completed In-Service Ethics, Sensitivity, First Aid, CPR and Defensive and Safety Training. Interviews with (R2-R10) revealed they all have utilized the transportation services provided in-house and felt safe during their transport services. (R2-R10) all claim that (S3) conducts himself professionally, communicates well and is committed to safety on the road. Interviews with (S1-S10) and (W1) all claim that accusation is manufactured and that (S3) is an excellent worker and well experienced and trained. Based on the information gather, there’s no evidence to collaborate the allegation mentioned above. Resident does not receive medication delivery in a timely manner. The detail of the allegation indicates the (R1) does not receive his medication delivery in a timely manner. Interviews conducted with staff #1-#2 (S1-S2) indicated (R1) is self responsible for his medications and does not need assistance with medication administration and that medications are sent to the facility by mail. (S1-S2) all stated that the mail is delivered to the resident the same day it arrives. The mail is delivered by USPS mail and is distributed by the administrator, med tech, or caregivers. The resident also comes to the front office to retrieve their mail. The administrator also stated that mail is received by the receptionist at the skilled nursing annex. Evaluation Report continues on LIC 9099-C The administrator then handles will separate it and gives the Assisted Living residents their mail daily. The administrator states, the mail delivery time may vary depending on the holiday that will affect the distribution process. The administrator claims the facility has no control over the USPS or any other mail services with the delivery schedules. A review of (R1)’s service records, confirms that (R1) is self-responsible for medications and refills. Interviews conducted with (R2-R10) reported they have no concerns with their mail and that it is being delivered timely. All the residents interviewed, there have been on knowledge with late mail delivery and stated they all had no difficulties receiving their medications timely. Based on the information gather, there’s no evidence to support the allegation mentioned above. Facility has insufficient staffing to meet the resident’s needs. The details of the allegation state there is insufficient staffing to meet resident #1 (R1)’s needs. Staff is not providing appropriate care and supervision to the residents while in care. On 7/14/2021 the Department interviewed residents #2-10 (R2-R10) regarding care and supervision. All the residents indicated that their needs are being met. When one calls for assistance, the staff provides them with what is needed. Information provided by residents states there is always staff around to provide you with care to assist with assisted daily living activities. During the interview with the administrator, she indicated that there is always staff on shift to provide care and supervision. The administrator states staffing availability for the following shifts: eleven (11) morning shift; seven (7) swing shift; five (5) graveyard shift the numbers do not include kitchen staff. The administrator claims that during any staffing crisis; the staff is crossed trained to assist immediately with any job function. The administrator provided proof to verify staff is cross-trained. Interviews were conducted with (S1-S10) all confirmed that there is sufficient staffing in each shift to accommodate residents with required needs and they are crossed trained if needed for any staffing crises. An interview with witness #1 (W1) indicated there has been no hint to (R1) not being care for or supervised timely and states the staff is doing the best they under circumstances have to assist with a variety of needs. A review of (R1)’s service records indicated the resident is very much independent and requires minimal assistance with care or supervision. Based on the information collected, there’s no evidence to collaborate the allegation mentioned above. Evaluation Report continues on LIC 9099-C The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R-1)'s service records, and interviews conducted and found no evidence to support the allegations: "Facility staff transports residents in an unsafe manner", "Resident does not receive medication delivery in a timely manner", "Facility has insufficient staffing to meet the resident’s needs". Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted with Elizabeth Hernandez and a copy of the report was provided by email.