complaint·November 3, 2021

LPA interviewed current and former staff #1-15 and #17-18 along with Witness #19 telephonically on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/2/2021, LPA requested copies of additional residents records. The investigation revealed the following: In regards to allegation, "Food service is inadequate," LPA interviewed staff in regards to meals served. (12) out of (18) staff members indicated they never seen any issues with the food the facility served and they quantity was enough. They stated the quality was also good and never heard of the facility running out of food. Staff indicated the residents had (3) meals a day and (2) snacks. In regards to allegation, "Facility has inadequate laundry service," based on interviews conducted (12) out of (18) interviews conducted stated they never had an issue with the laundry being done for the residents and never heard of the facility running out of laundry soap. Per interviews, the residents had their clothes washed by the laundry person and would get done. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with the Assistant Administrator, Laura Hernandez and Caregiver, Elvira Cortez and a hard copy was provided. current and former staff #1-15 and #17-18 along with Witness #19 telephonically on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/3/2021, LPA requested additional copies of residents records. The investigation for allegation #1 was referred to the Investigation Bureau and was investigated solely by Investigator Brian Slatic. He conducted interviews with current and former staff, family members, and also obtained relevant resident records. The investigation revealed the following: In regards to allegation: Lack of supervision resulting in resident sexually abusing other residents - During the course of the investigation, the investigator obtained information from individuals who personally witnessed many of the alleged actions and behaviors of Resident #9. Former staff members report seeing Resident #9 touch, fondle and rub female clients on their breasts and vaginal areas. Resident #9 was also found in another residents room, while the other resident had their pants down. Resident #9 was found in the bed of a female resident and caught taking a female dementia resident to the back area of the facility. Resident #9 also attempted to sexually assault a female resident while under the influence of drugs. Multiple staff informed Staff #1, who was the Administrator at the time of these incidents. However, no substantive action appeared to have been taken by Staff #1 or the Licensee to stop Resident #9's behaviors. The residents continued to be victimized by Resident #9. There is also no evidence that any of these incidents were reported to Community Care Licensing (CCL) or cross reported to other agencies. In regards to allegation: Facility has insufficient staff to meet the residents' needs - several former and current staff stated that at some point last year there wasn't sufficient staff at the facility. Staff members revealed that sometimes they did not have help for transferring residents to their beds or up from their beds who required a 2-3 person assistance to transfer. Staff also stated sometimes during the night shift there was only one (1) staff member from the hours of 11PM- to about 5AM because the second staff member would call off and the facility would not get coverage. Per interviews, it happened very often and the one (1) caregiver could not finish their rounds. Caregivers indicated sometimes they could not complete diaper changes at night when it was just one (1) caregiver. Some of the things caregivers stated they could not complete due to staffing issues was showers, repositioning and grooming. They also stated that breakfast was rushed and the residents were pressured to eat quickly so they can complete other duties. Per staff interviews, this was brought up to the attention of Staff #1 and the Licensee and nothing was ever done. (Continued on an LIC 9099C) In one instance, a caregiver was told that CCL did not mandate a staff to resident ratio and could have one (1) caregiver only for all the residents. Per interviews conducted, the total resident census at the time was between 25 -30 residents. LPA received photographs of residents left soiled on the floor, and bed rails not in place with bed sheets falling off the beds. Another picture received was of a resident naked from the waist down in a fetal position and their bed soiled with feces. In regards to allegation: Residents are restrained - it was alleged the facility was tying the residents with bedsheets to their wheels chairs and using Gerry chairs with a table tray on residents who did not have an order for the chair, and gait belts to keep the residents in place. Interviews conducted revealed a number of residents were tied with bedsheets to their wheelchairs in order to prevent them from falling off their wheelchair and to help caregivers complete their duties with other residents. Caregivers interviewed stated that they would have them tied from the waist to the wheelchair and sometimes from the chest to prevent them from falling and injuring themselves. Several current and former staff indicated that Resident #5 was put in Gerry chair with the table tray because the resident was very aggressive. LPA also received a picture of the resident in the Gerry chair with the tray on top of the resident. No physicians orders were observed in resident's file for the Gerry chair. LPA received pictures of another resident tied with a light blue/gray bedsheet around the stomach and chest area and the knot at the back of the wheel chair. In regards to allegation: Facility has scabies/C-diff outbreak- it was alleged a few residents had scabies and C-diff at the facility and that appropriate medical follow-up did not occur with the residents. It was also alleged staff was not notified or given proper instructions on handling contagious residents. Records reviewed revealed Resident #8 was diagnosed with scabies on 8/25/2020, Resident #6 on 8/27/2020 and Resident #13 sometime later that year. Interviews with staff revealed that they were never trained on how to handle residents with scabies or C-diff. Staff #1, who was the administrator at the time stated that Resident #6 and #8 did in fact have scabies. Per staff #1 both residents were room mates. Interviews with staff stated that Resident #8 had scabies first and later gave it to Resident #6. Per Staff #1, hospice said it was not scabies and later determined that it was. It was never reported to CCL. Staff #1 stated the Licensee, staff and families were notified. LPA received documents on todays visit from the County of Los Angeles Public Health being notified and a case being opened. In regards to allegation: Facility is in disrepair - it was alleged the facility had broken beds, clogged toilets, plumbing issues and the facility was in disrepair. (Continued on an LIC 9099C) Interviews with staff indicated the facility did have plumbing issue but was later fixed. Interviews with staff revealed the mattresses were dirty and old and some were placed directly on the floor without box springs or bed frames. Interviews also reveal that there is broken closet doors inside a resident's room. Picture was obtained. LPA obtained pictures of dirty mattresses with what appeared to be feces. LPA also obtained a picture with a ripped box spring with pillows in between the mattress and box spring and a resident laying on the bed and pictures of dirty mattresses. In regards to allegation: Residents are not provided with general hygiene supplies - it was alleged the facility had no soap, paper towels, and toilet paper and that the Administrator would lock away supplies making it inaccessible to staff during their shift. Based on interviews conducted, during the night shift staff couldn't ask for supply because management was not on the premises and would run out of supply during the night shift. Staff also stated that even during the day they do not get supply because the facility always runs out. Caregivers stated they had to use the same shampoo, bar soap, hairbrush, deodorant and toothpaste for all residents. Per caregivers, it's the facilities practice for each staff to carry their own small bucket with hygiene supply and assist the residents. The only thing the resident have of their own is their toothbrush. Staff also stated they would run out of wipes. Based on records reviewed, evidence, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies cited under California Code of Regulations Title 22 . Immediate Civil Penalties of $500 is being issued. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49 (f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000). An exit interview was conducted with Assistant Administrator, Laura Hernandez and Caregiver Elvira Cortez and hard copy of this report was provided along with appeal rights.