complaint·January 21, 2025

On the allegation " Licensee did not provide the facility with an up to date and readily available emergency disaster plan"; it is the concern of the reporting party (RP) that the community had no evacuation plan, and that it was complete chaos during an evacuation. To investigate the allegation the LPA conducted file review and interviews. Information obtained revealed that on 01/09/2025 the community had to evacuate due to the Kenneth Fire. File review revealed that the community has an Emergency and Disaster Plan (LIC610E) on file. A review of the LIC610E indicated that the community had temporary shelter locations, evacuation procedures and staff assignments during an emergency disaster. File review also revealed that the community conducts monthly emergency and fire drills with their last drill conducted on 12/03/2024. Eleven (11) out of thirteen (13) randomly selected residents that were interviewed revealed that they had no concerns regarding the evacuation, it was well handled, they were well taken care of, the staff did the best they could, and that the staff were knowledgeable on the evacuation process. All staff interviewed revealed that the community trained them and has a third-party individual that comes and educates them on what to do during an emergency and/or disaster such as a fire. Additionally, staff interviewed that were present during the evacuation revealed that considering the emergency they were prepared to the best of their ability, the community was getting ready for an evacuation days prior, all residents had evacuation bags ready to go, and they ensured the safety of the residents. Based on the information gathered, the above allegation is deemed unsubstantiated at this time. Exit interview conducted and report issued. On the allegation, “Facility staff are unable to provide medication as prescribed to residents during an evacuation”; it is the concern of the reporting party (RP) that residents had no medication or care during an evacuation. To investigate the allegation the LPA conducted interviews and a medication audit for three residents. Information obtained revealed that on 01/09/2025 the community had to evacuate to three relocation sites and several residents left with family members due to the Kenneth Fire. Staff interviewed revealed that medications and incontinence supplies were relocated to the relocation sites, and/or provided to family members that took residents home with them. Eleven (11) out of thirteen (13) randomly selected residents that were interviewed revealed that they had no concerns regarding the evacuation, it was well handled, they were well taken care of, the staff did the best they could, and medications were provided. However, two (2) out of thirteen (13) residents revealed that they were not provided medications during the evacuation. On 01/15/2024, the LPA conducted a medication audit for three residents and observed the following; Resident 1 (R1) had their evening medications, Eliquis 2.5 MG and Potassium CL ER 20MEQ , still in the bubble pack for 01/09/2025 and 01/10/2025. Resident 2 (R2) had their evening medication, Xarelto 20MG medication still in the bubble packs for 01/09/2025 and 01/10/2025. Additionally, based on a pill count for Resident 3 (R3) conducted by the Memory Care Director, the LPA observed that R3 was not provided their morning Letrozole .25MG medication on 1/10/2025. R1 and R2 were evacuated to one of the relocation sites, and R3 went home with family. An interview conducted with R3’s family member revealed that they were not given R3’s medications during the evacuation. Based on the information gathered through interviews, and medication audit, the allegation above is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Exit interview was conducted and a copy of the report and Appeal Rights were issued.