complaint·July 7, 2022

According to Investigation Bureau Investigator’s interviews with Administrator Ahmed and 6 staff in relation to this complaint, one of the staff (S-1) admitted that on 6/4/21, Resident #1 (R-1) had said all night that R-1 needed to go to the bathroom. Since S-1 had just finished putting on a fresh brief on resident, S-1 just checked on resident to see if it was soiled. S-1 also stated that it was the first night R-1 had made numerous requests to be moved to the toilet. S-1 did not believe R-1 truly needed to have a bowel movement and had never been required to move R-1 out of the bed to the toilet during the NOC shift. However, S-1 acknowledged that other residents on the NOC shift were transferred from their beds to the toilet. LPA Chan interviewed additional 3 Staff and confirmed that when a resident request to be changed or taken to the toilet, the staff must assist the resident even if the resident requires two people to transfer. LPA interviewed 3 residents today and they stated that staff are good and assist with diaper change and/or going to the toilet. Administrator Ahmed confirmed that S-1 had been terminated and no longer working at the facility. Based on interviews conducted, 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), is being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.