Complaint·August 9, 2023

Regarding Allegation #1 : this investigation revealed based on interviews conducted with Staff #1 - #4 (S1-S4), Residents #1 - #4 (R1-R4), and a review of the requested documents that the facility is following COVID-19 protocols. Administrator Park informed LPA Brown that the facility follows COVID-19 protocols during a COVID outbreak - including the facility’s mitigation plan. Administrator informed LPA that there is a weekly COVID testing for staff and residents and whenever there is a positive case, it’s reported to CCLD (via fax) and to the local public health department (via RedCap). Administrator also stated to LPA that facility staff encourages their residents to wear a face mask when inside or outside the facility. LPA conducted an inspection and observed the facility is following their mitigation plan measures. LPA interviewed four (4) facility staff members and 4 of the 4 staff members interviewed corroborated that they have been trained in COVID protocol procedures and that staff encourages the residents to wear their face mask while inside or outside the facility. LPA interviewed four (4) residents and 4 of the 4 the residents corroborated facility staff are following COVID-19 procedures when there are positive cases. Residents also confirmed that the facility provides them with face masks to use while inside or outside the facility. A review of the facility’s COVID-19 incident reports that were submitted to CCLD (via fax) documented notifications made to DPH (via RedCap) that was confirmed by Administrator Park. A review of the facility’s staff training records documented staff were provided with “COVID-19” training on various topics (i.e., Cleaning for COVID-19 (05/30/22); Guidance on 2019 Novel Corona Virus or COVID-19 (06/01/22); Donning & Duffing (06/14/22), Handwashing & 6-feet Distancing (06/16/22); Mask FIT Testing (06/17/22); Cough Ettiquette & Cleaning for COVID-19 (06/18/22). Based on the evidence gathered, interviews conducted, and records reviewed, 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 of OTHER: Staff did not follow proper Covid-19 safety protocols is found to be UNSUBSTANTIATED. Regarding Allegation #2 : this investigation revealed based on interviews conducted with Staff #1 - #4 (S1-S4), 4 of the 4 corroborated that staff do allow residents to have visitors. Administrator Park informed LPA Brown that during a COVID outbreak facility staff will contact the resident’s responsible person and encourage the family member(s) not to visit their loved one(s) while the resident(s) is in quarantine, and/or until their test result returns negative. In the memory care unit, visitors would visit their loved one(s) in the patio area. Facility encouraged an appointment to let facility staff know when a resident’s family was coming to visit their loved one at the facility to make sure there was enough space and to get the resident to the patio area for visitation. Administrator Park confirmed that when the facility had an outbreak, facility staff asked resident’s family to call ahead because the facility did not want to have a lot of visitors in one space to avoid spreading the virus. Although some resident’s family member(s) would show up unannounced to the facility, they would agree to visit their loved ones outside the resident(s) room and were never denied visitation. Interviews conducted with Residents #1 - #4, (R1-R4) 4 of the 4 the residents corroborated that facility staff allowed them to have visitors during COVID and were never denied of their visitation rights. RA Ceniceros observed COVID postings at the main entrance of the facility (photo). A review of the facility’s staff training records documented staff were provided with “PERSONAL RIGHTS” training on various topics (i.e., HIPPA Compliance (10/26/22) and Resident's Rights (12/22/22). Based on the evidence gathered, interviews conducted, and records reviewed, 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 of PERSONAL RIGHTS: Staff are not allowing resident to have visitors while in care is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to the new Administrator (Steve Cho).