complaint·December 12, 2023

The investigation of the above-mentioned allegations was conducted by the licensing agency's Investigation Bureau. The investigation was conducted by the assigned Investigator, Dennis Seng and consisted of the following: Interviews conducted with Administrator (S1) and Staff #2 - #3 (S2 & S3), Residents #1 - #4 (R1, R2, R3 & R4), Witnesses #1 & #2 (W1 & W2), and Staff at other agencies (W3 & W4), including Adult Protective Services and Long-Term Care Ombudsman program. Investigator Seng also reviewed R1's facility file/documentation, including incident reports dated 10/23/20, and medical records dated 11/03/20 and 11/06/20. The investigation revealed the following: Regarding allegation: Resident suffered a fall resulting in a fracture . It was alleged that R1, who was deemed a fall risk, fell over a raised threshold in the doorway while ambulating, due to staff failing to assist R1. Interviews with (4) of (4) staff indicated that R1 fell in the facility and that R1’s family did not want the facility staff to call 911. (3) of (4) residents interviewed could not corroborate the allegations. Per incident report dated 10/23/20, it was indicated that R1 had a fall at the facility, was helped back into bed, and responsible parties were notified. Interviews with W1-W2 revealed that on 10/23/20, R1 called W1-W2 regarding the fall and stated to be in pain and asked to go to the hospital. However, facility staff informed W1-W2 that staff were unable to arrange R1’s transportation. Interviews with W3-W4 revealed that R1 fell in the facility on 10/23/20 and was not seen by a medical professional until early November 2020. Review of R1's file revealed that R1 was a fall risk as indicated on R1’s Individual Service Plan, dated 09/17/20. Therefore, based on the investigation, the facility failed to provide resident with adequate care and supervision, which resulted in R1 falling and sustaining an injury. Regarding Allegation: Staff did not seek medical attention in a timely manner . It was alleged that after R1 fell at the facility while being a fall risk, R1 expressed pain to staff and requested an x-ray be taken; However, staff did not obtain medical treatment for the resident until a week later. During the investigation, Investigator Seng reviewed R1’s facility file/documentation, including incident reports dated 10/23/20, and medical reports dated 11/03/20 and 11/06/20. Per the incident report dated 10/23/20, R1 fell over a raised threshold in doorway at the facility while walking into R1’s room. R1 informed S3-S4 that R1 was in pain and wanted to go to the hospital to get an x-ray. Administrator and staff spoke with W1-W2, and per Administrator, W1 and W2 requested R1 not be sent out for medical treatment. Per medical records review, it was discovered that R1 did not receive medical treatment until 11/03/20, which was (11) days after the fall occurred 10/23/20. X-rays taken on 11/06/20 revealed that R1 sustained a fracture to the right hand. Therefore, based on the investigation, staff failed to seek timely medical attention for R1, after R1 fell at the facility and expressed pain to staff, which resulted in a fracture to R1's right hand. (Report continued on LIC9099-C...) Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegations are found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, and Chapter 8, deficiencies will be cited on the attached LIC9099-D. An immediate $500 civil penalty is being issued during today's visit due to the lack of care and supervision that occurred on 10/23/20 when R1 fell in the facility and sustained a fractured right hand. “The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).“ An exit interview was conducted and a copy of this report, along with appeal rights, were discussed and provided to Administrator, Jasbindar Singh. During today's visit, LPA Maldonado obtained a copy of the resident and staff rosters, Facesheet and Physician's Reports for Residents# 2, and #5-7 (R2, and R5-R7), and conducted a tour of the physical plant with assistance of Administrator Singh. Interviews were also conducted with Staff# 1 and #4 (S1 and S4), and attempted interviews with R2, and R5-R7. The investigation revealed the following: Regarding allegation: Facility is in disrepair. It was alleged that during the winter months of 2020, the facility heater was in disrepair for one month and delays in plumbing issues on a single toilet shared by (5) residents. Per interviews with staff, S1 stated that although the central heating system was not operating properly for a short period of time, individual heater units were brought in the home and each resident had one placed in their room. S1 also stated that although they did have a plumbing issue on Thanksgiving Day of 2020 in one restroom, the residents were able to use the other restroom in the home, as needed. S4 states no work receipt is available, but recalls the incident and stated that a plumber came the following day to repair it, as it was difficult to have anyone come out on Thanksgiving Day. S4 could not corroborate the allegation as S4 states to not have worked at the facility at the time of the alleged. (4) of (4) residents could not corroborate the allegation. During the tour of the physical plant, LPA observed the thermostat temperature set at 82*F inside the home. LPA observed all resident rooms and common areas to have heat vents, and observed them to be operating properly. LPA also inspected the (2) bathrooms in the home and observed them to be clean, sanitary, and were operable during the visit. Regarding allegation: Staff did not provide an adequate amount of food to resident. It was alleged that R1 did not receive enough food during meals and was given (4) yogurts for Thanksgiving dinner. (2) of (2) staff interviewed denied the allegations and stated that there is always sufficient amount of food/groceries available at the facility for residents. Staff stated that residents are provided with (3) meals and (3) snacks of their choice every day. (1) of (4) residents interviewed denied the allegation and stated that sufficient food is given during meals and snacks are always available. LPA attempted interviews with (3) of (4) residents- they could not corroborate the allegation. During the tour of the physical plant, LPA inspected the food supplies and observed a sufficient amount of perishable and non-perishable foods available for the number of residents in care, which included milk, eggs, vegetables, meats, cereals, cookies, oatmeal, pudding cups, and fresh fruits. (Report continued on LIC9099-C...) Regarding allegation: Resident was denied food. It was alleged that facility staff denied R1 more food, after not receiving enough food to satisfy R1's hunger. (2) of (2) staff interviewed denied the allegation and stated that there is always sufficient food at the facility to give to residents if they wish to have more. Staff also stated that the residents are allowed to take whatever they wish at any time from the kitchen or pantry. They may sometimes request it directly from staff and staff will assist the residents with it. Staff stated that residents are provided with (3) meals and (3) snacks of their choice, per day. (1) of (4) residents interviewed denied the allegation and stated that all residents are given whatever amount of food they want. LPA attempted interviews with (3) of (4) residents- they could not corroborate the allegation. During the tour of the physical plant, LPA inspected the food supplies and observed a sufficient amount of perishable and non-perishable foods available for the number of residents in care, which included milk, eggs, vegetables, meats, cereals, cookies, oatmeal, pudding cups, and fresh fruits. LPA did not observe any food items hidden, locked, or inaccessible to residents in care. Based on the LPA's record review, interviews, and observations, the investigation revealed: 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. An exit interview was conducted with Administrator, Jasbindar Singh, and a copy of this report was provided.