complaint·May 1, 2025

LPA de la Cerra’s interviews with staff #2 (S2) at 11:55am revealed that R1’s care and supervision was increased due to showing some signs of decline, confusion and bladder retention problems, S1 then instructed staff members to do hourly routine check for R1. Interviews with staff #3 (S3) at 3:05pm and phone interview with staff #4 (S4) on 4/30/25 who both were assigned on night shift (NOC) duty during April 2024 revealed that around the beginning of April, staff members were instructed to increase the routine check on R1 to every hour. Staff S3 and S4 did check in on R1 routinely every hour and the last check in would normally be at 6:00am when their shift would end. LPA de la Cerra’s interviews with staff members, staff #5 (S5) and staff #6 (S6) who were with the AM shift (starts at 6am) during April 2024 revealed that they checked in with R1 usually at 6:30am. and every hour thereafter. Interviews with caregivers, S3, S4, S5 and S6 revealed that although the check in with R1 was hourly but most of these check-ins with R1 would not be documented in the facility’s observation log. Caregivers are instructed that there is no need to document on the observation log if there are no changes observed with the residents or if they are just sleeping.. Interviews with residents reveal that they receive sufficient care and supervision from facility staff. Furthermore, interviews with staff # S2, S3 and S7 on 4/30/25, revealed that R1 did not like wearing incontinence underwear and the incident on 4/09/24 with the broken toilet could be due to R1 attempting to flush their incontinence underwear in the toilet which would cause the toilet to overflow and malfunction. Review of R1’s records reveal that due to R1’s change in health condition, R1’s individual service plan was modified, that facility staff will provide total assistance to R1 to ensure successful toileting. During LPA de la Cerra’s subsequent visit on 4/24/25, R1 was not available for interview, record review by LPA de la Cerra revealed the R1 no longer resides at Sparr Heights Estates Senior Living, R1’s Power of Attorney-POA moved R1 out of the facility on 3/18/2025. Based on inspection, observations, interviews and record reviews, there is insufficient information to support this allegation. Therefore, the allegation remains Unsubstantiated. CONTINUE to LIC9099-C Allegation: Staff spoke inappropriately while in front of resident. It was alleged that while the reporting party was with R1 in R1’s room, and a female staff with hair dyed pink or purple, who is Filipino said to the reporting party that R1 is “coo coo”. To investigate this allegation. LPA Rosaura Valenzuela conducted an initial visit and delivered findings on 4/15/2024. During LPA de la Cerra's subsequent visit, 0n 4/24/2025. LPA conducted physical plant tour, conducted record reviews and staff interviews between 10:30am to 12:00pm and 1:30pm to 3:00pm, resident interviews were conducted between 12:30pm to 1:30pm. LPA obtained the staff roster, resident list, and gathered additional documents pertaining to the investigation. During LPA de la Cerra’s physical plant tour, LPA did not observe any staff member with hair dyed pink or purple, who is Filipino. LPA de la Cerra’s interviews with staff #1 (S1) at 11:00am and staff #2 (S2) at 11:55am on 4/24/25 revealed that the facility did not have a Filipino staff member with hair dyed pink or purple around April 2024. Interviews with residents reveal that they have never been spoken to inappropriately by any staff members. Additionally, residents interview also revealed that no staff member ever spoke inappropriately about them in front of their family member. During LPA de la Cerra’s subsequent visit on 4/24/25, R1 was not available for interview, record review by LPA de la Cerra revealed the R1 no longer resides at Sparr Heights Estates Senior Living, R1’s Power of Attorney-POA moved R1 out of the facility on 3/18/2025. Based on inspection, observations, interviews and record reviews, there is insufficient information to support this allegation. Therefore, the allegation remains Unsubstantiated. No health and safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.