complaint·April 10, 2024

It was alleged that residents bedroom #3 and bedroom #4 was used as a passageway for staff to enter the garage (staff bedroom) or exit the facility. To investigate the complaint, LPA interviewed staff and residents from 10:30-11:30 AM. LPA interviewed four (4) out of four (4) staff and four (4) out of five (5) residents. During the interview for the residents, R2 who resides in bedroom #4 stated that their bedroom is used as a passageway that leads to the garage, which is the staff bedroom. R2 spends most of their time in their bedroom and stated that staff would enter bedroom #3 and bedroom #4 without knocking, look at R2, and just walk by to use the exit door that leads to the garage (staff bedroom) or exiting the facility. R5 is bedridden and advised LPA that their bedroom #3 is used as a passageway to exit the facility. Therefore, this allegation is SUBSTANTIATED. Allegation: The garage is used as a living space for staff. It was alleged that the facility used the garage as a staff living space. According to the facility sketch and observation on 12.5.2023, the facility is approve for four (4) bedroom, garage as a storage, kitchen, living room and two (2) bathrooms. To investigate this complaint, during LPA facility tour at 10:05 AM. LPA observed that the garage has an air-conditioning unit, queen mattress with full bed frame, sofa, incontinent supplies, staff belongings, PPE storage and staff refrigerator. Four (4) out of four (4) staff confirmed that the garage is where staff sleeps. Three (3) out of five (5) residents confirmed that the staff lives in the garage. Licensee and staff confirmed that the garage is not permitted for living/sleeping area, it is only for storage. The garage has a male and female staying in the garage room and was later identified as administrator's parents that are hired to be the staff in the facility. Licensee acknowledged that staff do sleep in the garage area. Licensee reported that they will not allow any person(s) to reside in the garage any longer and staff schedule for LIC 500 will be updated. Based upon the findings of the investigation, the above allegation is deemed SUBSTANTIATED at this time. Following citation is issued for the identified deficiency pursuant to Title 22 regulations. Exit interview conducted, appeal rights discussed, copy of this report is provided .