Complaint·September 6, 2024

The investigation revealed the following: Allegation: Staff does not ensure resident is allowed to leave the facility at any time with visitors. It is being alleged facility staff is not allowing R1 to leave the facility with visitors. On 08/16/24 between 12pm- 1:15pm LPA interviewed with ED regarding the allegation above, ED denied the allegation above and reported the facility is following POAs request regarding visitations outside the facility. ED continued to report that R1 has restrictions set in place by POA and that visitor(s) are aware of the restrictions. On 08/16/24 between 12pm- 1:15pm LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported that residents are allowed to go out of the facility with visitors unless there are restrictions in place per POA. On 08/16/24 LPA conducted interview with responsible party for R1, responsible party informed LPA that R1 has restrictions for visitations outside of the facility due to financial abuse concerns. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R1 regarding the allegation above, R1 reported it is not allowed for R1 to go out into the community with visitor although R1 would like too. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R2-R10 regarding the allegation above, 6 of 9 residents interviewed denied the allegation above and reported bring able to leave the facility with visitors, 2 of 9 residents interviewed reported not being able to leave the facility unaccompanied, 1 of 9 residents interviewed reported choosing to stay in the facility. On 09/04/24 LPA conducted review of the California all-purpose certificate of acknowledgment dated April 29, 2021 part 1 which is titled: Appointing an agent to make health care decisions, which reads “In this document I appoint an agent. That agent will make health care decisions for me in the future, if and when I no longer have the mental capacity to make my own health care decisions.” On 09/04/24 LPA reviewed provider information notice PIN 21-48-ASC page 3 title “Residents’ Right to Visitors, Telephone Calls, and Personal Mail” which details what POA agents are limited to the powers granted in the POA document. On 09/04/24 LPA conducted a review of title 22’s personal rights. Based on records reviewed and interviews conducted facility staff violated R1 personal rights by allowing a POA that only has the authority to make health care on behalf of R1 to make decisions on R1 personal rights. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division ( 6 ) and Chapter 8 are being cited on the attached LIC 9099D. exit interview conducted with Executive Director Suzette Johnson, appeal rights explained, and a copy of this report was provided. Allegation: Staff did not ensure resident was allowed to have visitors It is being alleged that facility staff do not allow residents to have visitors. On 08/16/24 between 12pm- 1:15pm LPA interviewed with ED regarding the allegation above, ED denied the allegation above and reported that visitors are always welcomed during visitation hours. On 08/16/24 between 12pm- 1:15pm LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported visitors are allowed daily. On 08/16/24 LPA conducted interview with responsible party for R1, responsible party stated that there are no visitor restrictions for visits conducted inside the facility. On 08/22/24 LPA between 9:30am-11:45am conducted interviews with R1 regarding the allegation above, denied the allegation above and reported having visitors. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R2-R10 regarding the allegation above, 7 of 9 residents interviewed denied the allegation above, 2 of 9 residents interviewed reported not having any visitors that come by the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. exit interview conducted with Executive Director Suzette Johnson, and a copy of this report was provided.