complaint·October 28, 2022

(continued from LIC 9099) During the course of the investigation, Investigator Spindola interviewed the Assistant Administrator, staff and family member on different dates and time from 05/13/21 to 07/17/21. IB Investigator Spindola also reviewed Hospital Records on 05/24/21 and 07/07/21 and Los Angeles Sheriff Department (LASD)’s record on 07/09/21. Regarding the allegation that lack of care and supervision resulting to multiple falls sustaining severe injuries, it was alleged that Resident #1 (R1) had fallen four (4) times between the period of 12/07/20 to 04/02/21 resulting to multiple injuries. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be, due to lack of staff. LPA’s record review on 10/20/22 at around 1:45 PM revealed that the last Functional Needs Assessment and Functional Needs and Services Plan for R1 was done on 03/25/21. The need of assistance on the document was scored by the points. R1 was a fall risk resident and required “stand-by/remind” assistance 3 x per day and escort assistance as needed but scored “0” on the assessment. On the status check also R1 required “stand-by/remind” assistance 3x a day but scored “11” on the assessment. IB Investigator’s interview with Staff #1 (S1) on 07/14/21 at 2:30 PM, revealed that on 04/30/21 S1 saw R1 on the hallway but was unable to help R1 because S1 was assisting another resident. By the time S1 rushed to assist R1, resident was found on the floor. Investigator Spindola’s interview with Staff #2 (S2) on 5/17/21 at 12:30 PM also revealed that R1 fell twice on 04/30/21 between 8:00 AM to 9:00 on the first fall and at 11:15 AM, R1 was hospitalized on the 2 nd fall, and no one witnessed R1 falling on both incidents. Regarding the allegation that due to insufficient staffing residents needs were not met, it was alleged that the memory care unit was understaffed. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be due to lack of staff. LPA's interview with four (4) staff on 03/26/22 between 10:00 AM to 2:00 PM and two (2) staff on 04/03/22 between 10:00 AM to 1:00 PM however, revealed that five (5) of six (6) staff interviewed between 03/26/22 and 04/03/22 believed that there is sufficient staff working at Memory Care unit during this time period. Based on the information gathered during the course of the investigation, the allegations are deemed substantiated at this time. Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued. (continued from LIC 9099-C) Regarding the allegation that due to insufficient staffing residents needs were not met, it was alleged that the memory care unit was understaffed. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be due to lack of staff. LPA's interview with four (4) staff on 03/26/22 between 10:00 AM to 2:00 PM and two (2) staff on 04/03/22 between 10:00 AM to 1:00 PM however, revealed that five (5) of six (6) staff interviewed between 03/26/22 and 04/03/22 believed that there is sufficient staff working at Memory Care unit during this time period. Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time. Citation issued, appeal rights discussed and given.