Complaint·March 7, 2023

On 3/7/23 LPAs requested copies of eviction letter and documentation on eviction process for R12, and notice to all residents. The investigation revealed the following: Regarding allegation: Resident sustained an injury while in care. It is alleged R11 fell late at night and hit his/her head and bled all over his/her room. Documents review revealed incident report on 4/28/22 R11 was found on the floor with a face laceration, facility send R11 to the hospital for evaluation and was transfer to a Skill Nursing Facility (SNF) after hospitalization. Physician report dated 5/7/22 notes R11 does not have any physical or mental limitations. Medical record dated 4/28/22 notes R11 was seen by a physician for a laceration to his/her face due to an unwitness fall. Per health and wellness notes dated 4/18/22 R11 did not required wellness checks or additional services, and a note was added on 4/18/22 to provide medication assistance. No other notes on change in condition, or notes on previous incidents were found. LPA Flores was unable to interview R11, as R11 passed away on 1/10/23 per death report dated: 1/12/23. Per Executive Director R11 was receiving independent living services and did not required constant checks. Interviews with residents revealed 6 out of 10 residents interview stated staff respond when they need assistance. 3 out of 10 residents stated to not need assistance and are independent and 1 out of 10 residents stated staff did not respond when assistance was needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Resident is threatening the safety of other residents. It is alleged R12 leaves the facility and returns intoxicated and has been threatening other residents with physical violence and obscenities. During document review physician's report dated: 12/27/21 for R12 was observed which notes R12 is able to manage care for self. Incident report dated: 4/14/22 notes R12 yelling at staff. Incident report dated: 4/19/22 notes R12 had agressive behaviors towards staff, 911 was called and R12 was taken by Los Angeles Police Department (LAPD). On 3/4/22 R12 was provided a 30 day notice to terminate Resident Agreement due to failure to comply with the general policies of the community. The notice to terminate list 6 incidents between February and April 2022 in which R12 had "problematic behaviors". Facility contacted 911 on 2/27/22, 3/3/22, and 4/19/22 to assist with R12. R12 property was removed from the facility on 6/14/22 after the process of an unlawful detainer file on 4/19/22. A letter to the residents was send out on 4/19/22 in regards to their concerns with R12 to notify them that facility is ensuring the health and safety of the residents. (CONTINUED ON LIC 9099C) Interviews with residents revealed 5 out of 10 residents stated there was a resident that was aggressive, however not physical who is no longer at the facility. 2 out of 10 residents interview stated there are no aggressive residents. 3 out of 10 residents stated not to know anything about other residents. Interviews with staff revealed 5 out of 7 staff stated there was a resident who was aggressive but not physically towards other residents rather to facility's property. 2 out of 7 staff stated they are not familiar with any resident behaving aggressive. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff do not meet qualifications for the job duties they are performing. It is alleged housekeeping staff are forced to work overtime and cover shifts for the CNAs even though they are not qualified. Interview with Executive Director revealed that housekeeping staff have performed caregiver duties as part of training for those who desire to move positions. This are performed outside staff's shift and performed on over-time and with supervision of a train staff. Housekeeper interview denied performing duties other than duties related to the job during their shift. 7 out of 7 staff stated to have received initial training related to their job duties and additional training after. 10 out 10 residents stated to feel staff are qualified to perform their duties. Documents reviewed show staff obtained initial training in their areas of responsibilities. Additional training was observed for housekeeping staff #5(S5) related to nurse aide duties dated 12/4/21 as part of a 5 day training. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Lyon O'Quinn Executive Director and a copy of this report was provided.