complaint·February 27, 2023

Facilities for the Elderly (RCFE) LIC602A dated 5/19/21, Appraisal/ Needs and Services Plan dated 1/1/21 and 1/1/22, Two letters addressed to R1 dated 3/10/22 and 3/15/22, Unusual Incident/ Injury Report LIC624 dated 2/28/22 and 3/25/21. LPA also conducted a tour of facility which included observations of common areas, lobby, Resident Cottage 1511 and bathroom. LPA tested water temperature and observed a reading of 111F. On 02/27/23, LPA collected copies of Staff/ Resident Rosters, reviewed 5 Resident files and collected copies of documents pertinent to the investigation. LPA conducted a tour of facility which included observations of common areas, facility lobby/ main entrance, all facility exits, Resident Cottages 1511 and 1515, designated smoking area and random resident rooms. LPA tested the water temperature in resident bathrooms and observed readings between 108F to 111F. LPA additionally observed and tested the signal system switches and tested the signal systems in random resident rooms. Investigation revealed the following: Regarding allegations, Resident sustained a bruise while in care and Facility staff did not seek timely medical care for resident , it is alleged a facility resident (R3) pushed another facility resident (R1) in the facility lobby in front of Facility Staff, Martha Marcheque. It is alleged that this incident occurred in October 2020 and that Staff Martha Marcheque took pictures of R1's bruised hip. R1 was allegedly not taken to see their doctor and R1 is currently limping from the pain on their hip. Interviews conducted with facility administrator, Staff Martha Marcheque and additional facility staff revealed that there was not an incident in which R3 pushed R1. Staff Marcheque denies that she witnessed R3 push R1 on or around October 2020 or at any other time and also denied taking pictures of R1’s hip area. Staff stated that if any facility resident suffers a fall or has any type of accident, facility staff will immediately provide affected resident(s) with first aid and if a higher level of care is needed, they will transport the resident to the hospital, urgent care or take the resident to their primary physician. R3 denied pushing R1. LPA reviewed facility Unusual Incident/ Injury Report LIC624s from October 2020 to present and did not observe a report of any altercation between R1 and R3 resulting in an injury to R1. Interviews conducted with 4 out of 5 residents revealed that they have not observed any resident push another facility resident and they also stated that if they need timely medical care it is provided to them. Based on interviews conducted with facility staff, residents and LPA record review, there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff are locking the fire exit doors, it is alleged that there are five fire exits at the facility that are locked by facility staff and residents cannot use them as fire exits. Interviews with facility staff revealed that facility exits are not locked and stated that facility exit doors are accessible for residents and staff when needed. Administrator stated that fire drills are conducted every 3 months and stated that since the investigation of Complaint Control #: 28-AS-20200623152228, staff are no longer locking any doors. He stated that during the height of the COVID19 pandemic the front door was being locked but they are no longer doing that. Interviews conducted with 4 out of 5 residents revealed that they have not observed that any of the facility doors are locked and stated that they are able to use facility exit doors. 1 resident stated that in June 2020, CCLD had Substantiated an allegation of Staff are locking the main entrance door. LPA observations revealed that facility exit doors are not locked and LPA reviewed fire drill report dated XX/XX/22. Based on interviews conducted with facility staff, residents, LPA observations and record review there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility did not keep hot water temperature within allowable range, it is alleged that faucet water in resident’s restroom takes a long time to heat up and once the water does heat up the water is then too hot for residents to use. Interviews with staff revealed that facility water temperature is kept with Title 22 regulations of 105 -120 F. Staff stated that water heats up at an adequate time and does not take a long time to heat up. Staff deny that once the water heats up it then becomes too hot for residents use. Interviews with 4 out of 5 residents revealed that they are satisfied with the water temperature at the facility. They stated that the water never gets so hot that they cannot use it. LPA tested the water temperature in 3 resident bathrooms and observed that the temperatures were within Title 22 regulations. Water temperature tested between 105 – 120 degrees Fahrenheit. Based on interviews conducted with facility staff, residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility staff are harassing resident, it is alleged that two facility staff, Jorge Perez and Maria Lacayo, harass R1 multiple times by telling R1 to "hurry up" while R1 is limping in the facility hallways. Interviews conducted with facility staff, Jorge Perez and Maria Lacayo revealed that they do not harass R1 or any other facility resident. Staff Lacayo and Perez deny ever telling R1 to hurry up while R1 is walking around in the facility. They stated that the facility hallways are large enough to give residents space to walk while the staff are tending to their duties. Administrator and facility staff deny that facility staff harass R1 or any other facility resident and stated that staff always treat all facility residents with respect. Interviews conducted with 4 out of 5 residents revealed that staff do not harass them and have not seen staff harass R1. LPA observed staff interacting with facility residents including R1 and did not observe staff harass any facility resident. Based on interviews conducted with facility staff, residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility not upholding resident's admission agreement, it is alleged that the facility is not upholding the admission agreement by allowing R3 to smoke in their room instead of the assigned smoking area(s). Interviews conducted with facility administrator and Staff revealed that residents that smoke are only allowed to smoke in the designated smoking areas and at no time are ever allowed to smoke in their rooms. Staff stated that there are some residents that do smell like smoke when they come into the facility after smoking but are never allowed to smoke inside the facility or their bedrooms. Administrator stated that the facility upholds resident’s admission agreements at all times and stated that if a resident is not adhering to or breaking any facility rules proper follow up and action will be taken. Interviews conducted with 4 out of 5 residents revealed that they have not seen any facility resident smoke inside the facility bedrooms and stated that people that smoke do so in the designated smoking areas. 1 out of 5 residents denied smoking in their room and stated that they only smoke in the designated smoking area. LPA observed residents smoking in designated smoking areas during the tour and did not observe any resident smoking in a nonsmoking area. Based on interviews conducted with facility staff, residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility's auditory signal system is not working properly, it is alleged that the auditory signal from the signal system at the facility has not been working and/or the noise is very low that staff cannot hear it. Residents only get assistance by walking to the main lobby and tracking staff down. Interviews conducted with Administrator and facility Staff revealed that the facility’s auditory signal system is working properly. They stated that resident bathrooms have a signal system/ pull cord. Staff interviews also revealed that some of the signal systems function either by a cordless switch or a switch that has a cord integrated. Interviews with 4 out of 5 residents revealed that they are aware as to how the signal switches and cords operate and stated that the signal system is properly working. LPA toured the facility bathrooms, observed and tested the signal system switches. LPA also observed and tested the signal systems in random resident rooms. All tested signal systems were operable. Based on interviews conducted with facility staff, residents, and LPA observations, there was not enough supportive evidence to concur with the reported 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 held. A copy of the report was provided to Assistant Administrator Alise Nazarian.