complaint·April 5, 2021

The investigation revealed the following: Staff did not meet residents needs R1 stated that staff do not meet resident needs outside of normal working hours. Interviews with staff revealed that there are 2 live-in staff and and 2 non-live in staff. All staff stated that the staff provide care even during non-working hours to meet residents needs. S3, house manager, stated that the live-in staff work 2 hours of overnight shift in addition to their day shift. 2 out of 3 residents interviewed stated that staff meet residents needs and they have observed staff helping at all hours. Staff did not seek timely medical care Interviews with back-up administrator Trupti Mody revealed that on 7/19/20, R1 was found by S2 collapsed on the floor at approximately 6:00 a.m. She stated that paramedics were called and R1 was admitted to the hospital by 7:03 a.m. S2 stated that he discovered R1 on the floor, asked him if he was okay, and helped him to the bed. He told S1 to call 911 shortly after helping R1 back to the bed because he noticed bleeding from the resident's forehead. A review of the incident report from the fall dated 7/19/20 confirmed that S2 found R1 on the floor with blood on his head. S2 helped R1 into bed and asked if he needed to go to the hospital. R1 said yes so S1 called 911. Paramedics arrived and transported him to Pomona Valley Hospital. A review of the discharge papers shows that he was discharged from the hospital at 10:43 a.m. Facility is in disrepair During the observation, LPA observed that all toilets in the facility flushed with toilet paper without overflowing. 2 out of 3 residents interviewed stated that the toilet is working. S3, house manager, stated that the toilets are working but they did have a plumbing problem that was fixed a few months prior. She stated that they have not had issues with the toilets since then. S1 and S2 stated that they don't give toilet paper to residents because some have dementia and will fill the toilets with toilet paper, so they ask residents not to put the toilet paper in the toilet and instead put it in the trash. They stated that the toilets work but that they do this as a preventative measure. Back-up administrator Trupti Mody stated that residents can put toilet paper in the toilets as long as it's not too much to cause overflowing. Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated. A telephonic exit interview was conducted with house manager. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.