complaint·July 27, 2023

In regards to the allegation of "Facility has inadequate record keeping" it was alleged that the the facility file for R1 was not available for review as it could not be located in the facility. (4) of (5) Staff interviewed could not provide information regarding the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. Details state that a Long Term Care Ombudsman staff requested documents for R1 from the facility on April-May 2021. Staff interview confirmed that the file for R1 was not able to be provided as it could not be located in the facility. Initial visit interviews conducted on 5/13/21 by LPA Kruz confirms that that R1's file could not be located in the facility. R1 was discharged from the facility on 10/25/18 and per regulations the file for R1 should have been kept for a minimum of 3 years from that date. This means R1's file should have been on site and available for review until 10/25/21. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview conducted and a copy of this report was provided. Appeal Rights were discussed and provided as well. In regards to the allegation "Resident sustained unexplained injuries while in care" it was alleged that R1 sustained unexplained bruising in their arms and legs. (5) of (5) Staff interviewed denied the allegation. (7) of (7) Residents could not corroborate the allegation. LPA Villalobos reviewed the hospice agency notes for R1 and did not observe documentation of bruising to R1's legs or arms. Notes stated that R1 was receiving wound care on their arm and their wrist. Staff interviews do not show that R1 was injured by any staff or to have observed R1 injured themselves. LPA was not provided with documentation of R1 having unexplained injuries in the facility. At the time of this visit, there is no resident file for R1 as the facility only keeps records for a minimum of 3 years and R1 has not been a resident since 10/25/18. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the allegation. 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 conducted and a copy of this report was provided.