complaint·October 11, 2021

Allegation: Lack of supervision resulting in resident to resident abuse. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed R-7 and R-8 would come in and out of this facility independently. Interviewed staff indicated Residents, at times, will get into verbal altercations and does not lead to physical contact. Per interviews, Staff are able to redirect Residents when this occurs. Interviewed staff indicated that they have not witnessed nor heard anyone stating that residents are being abused. Interviewed staff indicated that staff provide care and supervision to residents. Interviewed residents indicated there is staff providing care and supervision for residents. Interviewed residents indicated they have not witnessed any residents to resident abuse. Staff and Resident interviews do not corroborate this allegation. Allegation: Staff do not meet the minimum qualifications required by licensing During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed that staff are trained in resident rights, reporting requirements, supervision, resident abuse. Interviewed Residents were unable to provide an answer to this allegation as they do not know the minimum qualifications by licensing. Interviews do not corroborate this allegation. Allegation: Resident wandered away from the facility while in care During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Per staff interviews, R-7 and R-8 did not wonder out of this facility and indicated that R-7 and R-8 would go out in the community independently and return to this facility. Interviewed staff indicated residents do not wonder away from this facility. Interviewed residents indicated they have not witnessed nor heard of any residents wandering away from this facility. Interviewed residents indicated that residents whom leave the facility are independent and return to the facility. Per Staff interviews and record reviews, both R-7 and R-8, were independent and able to be out in the community unsupervised. Interviews and file reviews do not corroborate this allegation. 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. Exit interview conducted, copy of this report and appeal rights were provided to S-1. Allegation: Staff failed to properly report incidents regarding residents. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed that staff are trained in reporting special incidents. Interviewed staff indicated that it is responsibility to report special incidents to the Facility Administrator and in turn, the Facility Administrator reports the incidents to the appropriate entities. LPA was unable to obtain any special incidents for R-7 or R-8. Per staff interviews, R-8 indicated R-8 hit R-7 and staff interviewed all Residents. Per Staff interviews, no residents witnessed R-8 hitting R-7. Per file review, staff only had a hand written note on R-7’s and R-8’s file and was not reported to Licensing but was reported Long Term Care Ombudsman (LTCO). Per staff interviews, staff were under the impression that LTCO cross reports to Licensing. Per Staff interviews and record reviews, both R-7 and R-8, were independent and able to be out in the community unsupervised. Interviewed Residents were unable to provide an answer to this allegation as they do not know the special incident report guidelines. Staff interviews and file review corroborates this allegation. Based on observations, interviews and 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. A copy of this report and appeal rights were provided to S-1. NOTE: LPA was experiencing technical difficulties during today's visit.