complaint·November 25, 2024

(Continued from LIC9099) On the other side of the door LPA Rios pushed at the door to attempt to open, door did not open, door is not delayed egress. From 10:05 a.m. – 12:00 p.m., LPAs interviewed the Assistant Administrator, three (3) staff, and seven (7) out of nine (9) residents, who were able to communicate. At approximately 1:30 p.m., LPAs requested copies of pertinent information which include, but not limited to LIC610E, STD850, evacuation diagram, unusual/injury incident report, and most recent fire inspection. Allegation: Facility failed to keep passageways and stairways free of obstruction. Regarding the allegation, it is alleged that on the second floor, resident windows are bolted shut and exit doors are locked. To investigate the allegation LPAs conducted a physical plant tour which revealed one (1) out of two (2) exit doors, as per facility evacuation sketch, was locked by keypad device. LPA’s interview with the assistant administrator revealed the door is delayed egress, but later after speaking to the administrator by telephone clarified the door is not delayed egress. Assistant administrator revealed that on 11/08/2024, the facility fire inspection did not find an issue with the door being locked as it opens during an emergency. Review of unusual/injury incident report submitted to the department revealed facility self reported a resident caused a “small” fire and was sent to a hospital, no injuries reported. Interviews with seven (7) residents who responded to questioning revealed a fire had taken place in the facility with residents reporting making various observation such as, hearing fire alarms, seeing smoke, people running, the fire department utilizing a fire hose and fire extinguishers. One (1) resident revealed they saw a resident with burn injuries on face and hand. Three (3) out of the seven (7) residents who responded to questions stated they were on the second floor during the fire and evacuated using the elevator or door at the other end of the facility. Seven (7) out of seven (7) residents reveled having knowledge the door closest to the entrance is locked. LPA’s interview with staff revealed hearing about the fire or witnessing the fire take place. LPA’s tour of five (5) resident rooms found windows are not bolted shut but may be difficult to open. Interviews with all but one (1) out of the seven (7) residents that responded revealed they felt staff appropriately handled emergency protocols. LPA's met with Administrator Jessica Palaya and conducted an interview at approximately 2:34 p.m. According to administrator resident mentioned on incident report did not have injuries and there were no injuries caused by the fire. Administrator requested fire inspection from Fire Marshall. A copy will be sent to LPA when facility receives inspection documents. Based on LPAs' observation, interview and records reviewed the facility has one (1) of two (2) designated exit doors on the second floor locked with a keypad device which obstructs the door from opening. Therefore, the allegation is deemed substantiated at this time. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal rights provided. Copy of the report provided.