Complaint·March 20, 2025

Allegation #1: Staff left residents in soiled diapers for a long time. The investigation revealed the following: Regarding the allegation Staff leave residents soiled for an extended period, it is alleged that residents go hours without being changed and remain in soiled and dirty diapers. On 12/03/2024, between 10:30 am -12:30 pm, LPA Richard interviewed three (3) residents #2-4 (R2-R4) 3 out of 3 denied the allegation and stated that they are changed every one to two hours daily. LPA interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated that all the residents are being changed every 2 hours sometimes sooner if tan accident happened before or after the time to change passed. LPA interviewed administrator#1 (A1) who stated that the residents are checked every 1 - 2 hours. Record review of changing schedule (dated 11/01/24 to 11/30/24), has a schedule of all the name of residents who wears a diaper on when to be changed. LPA Richard was not able to interview R1. Regarding the allegation: Staff leave residents soiled for an extended period, based on interviews, the Department found no evidence to support the allegation mentioned above. 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. As a result, the allegation is Unsubstantiated. Report Continues, see LIC9099C Allegation #2: Staff did not ensure that residents were fed. The complainant alleges that staff did not ensure residents were being fed and not being woken up to eat. LPA interviewed administrator #1 (A1) Maria Bravo about the allegation. A1 stated that meals are served on the third floor at 8 am, 11:30 am, and 4:30 pm like clockwork. If a resident does not come to eat in the dining room, the staff would go and knock on the resident's room and ask if the residents want to have the breakfast brought to the room. The Administrator stated that the staff serves a well-balanced meal with a variety of food options to choose from each day. On 12/03/2024, between 10:30 am - 12:30 pm, LPA Richard interviewed six residents #2 (R2-R7) 6 out of 6 denied the allegation and stated that the facility would go to their room and knocked on the door to make sure they had breakfast, lunch and dinner, in the dining room. They also stated that they did not have any problem with the food. On 12/03/2024, between 12:30 pm and 2:00 Pm, LPA Richard interviewed six (6) staff #1-6 (S1-S6) 6 out of 6 stated that they make sure the residents eat every day, if the residents did not want to eat the staff would talk to them to found out if they wanted to eat something else. LPA reviewed the facility menu for the week and observed a variety of food options listed on the menu. LPA was unable to interview R1. Regarding the allegation, Staff did not ensure that residents were fed, Based on interviews and records review, the department found no evidence to support the allegation mentioned above. 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. As a result, the allegation is Unsubstantiated. Report Continues, see LIC9099C Allegation #3: Staff verbally abused resident in care. The complaint alleged that the facility verbally abused residents due to retaliation if they reported the abuse. On, 12/03/2024, between 12:00 pm and 2:00 pm LPA interviewed administrator #1 (A1) about the allegation A1 denied the staff ever verbally abusing the clients. (A1) stated that they respect all the clients, and they go out of their way to help their clients because they want the clients to feel comfortable and have the freedom if they were in their own homes. On 12/03/24, between 10:30 am -12:00 pm, LPA interviewed six (6) residents (R2-R7), 6 out of 6 stated that since they have been living there, the staff had never verbally abused them. On 12/03/24, between 12:00 pm – and 2:00 pm, LPA interviewed six (6) staff (S1-S6), 6 out of 6 denied the allegation and stated that they had never witnessed other staff verbally abuse the clients, on the contrary, the residents were the ones who verbally abused and threatened the staff. The staff also stated that they have taken training regarding clients’ rights. LPA Richard was unable to interview R1. Regarding the allegation, Staff verbally abused a resident in care. Based on interviews, the department found no evidence to support the allegation mentioned above. 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. As a result, the allegation is Unsubstantiated. Report Continues see LIC9099C Allegation #4: Staff threw resident’s personal belongings. It is being alleged that staff entered the resident's room and threw the resident's clothes and shoes on the floor. The department interviewed administrator #1(A1), who stated that the staff never entered the resident's room and threw their clothes and shoes on the floor because the staff knows the residents have rights, the staff needs permission from the resident to even throw away expired food inside the refrigerator. On 12/ 03/24, between 10:30 am -12:00 pm, LPA interviewed six residents #2-7 (R2-R7) 5 out of 6 stated that the staff never threw their clothes on the floor. The staff always asked them if they could throw away the expired food inside the refrigerator when cleaning the room. On 12/03/24, between 12:00 pm- 2:00 pm, LPA interviewed six (6) staff #S (S1-S6), and 6 out of 6 stated that the resident has the right to say no to us and we cannot throw away their stuff. The staff also stated that they have not received a complaint from the resident in care that facility staff threw away their stuff. LPA was unable to interview resident R1. Regarding the allegation, Staff threw the president’s personal belongings. Based on interviews, the department found no evidence to support the allegation mentioned above. 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. As a result, the allegation is Unsubstantiated. Report Continues, see LIC9099C Allegation #5: Staff made a false report about a resident in care. The complaint alleged that the staff made a false report about a resident, resulting in the facility calling law enforcement and filing false reports to get the client arrested. On, 12/03/24, between 12:00 pm – 2:00 pm, LPA interviewed administrator #1 (A1), who stated that the facility did call law enforcement for the resident it was a resident, who was choking one of our residents. When police arrived, the victim didn’t want to press battery charges. On 12/03/24, between 12:00 – 2:00 pm, LPA Records reviewed of law enforcement report receipt dated 11/23/24 and confirmed that law enforcement did receive a call from the facility about an altercation. The department interviewed six residents #2-7 (R2-R7), and 6 out of 6 stated that they didn’t know anything about the staff making false reports about them, all they knew was that the staff always tried to help when there was fighting among the residents. LPA was unable to interview R1. Regarding the allegation, Staff made a false report about a resident in care. Based on interviews, and record reviews, the department found no evidence to support the allegation mentioned above. 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. As a result, the allegation is Unsubstantiated. Report Continues, see LIC9099C Allegation #6: Staff prevented the resident from having a visitor in care. It is being alleged that the staff is not allowing the resident visitors to visit residents and stated that the resident is not there. On 12/03/24, between 12:00 pm -2:00 pm, LPA interviewed administrator #1, Maria Bravo (A1), who denied the allegation. A1 stated that all the residents have visitors seven days a week. If the residents share rooms, the residents cannot have visitors inside the room, unless it’s a private room. On 12/03/24 between 12:00 pm - 2:00 pm, LPA interviewed the facility front desk (S2) and stated that most of the residents have visitors, and they must sign in and out. Sometimes, the family members refuse to sign in and out, but we never denied them entry. On,12/03/24, between 10:30 am -12:00 pm, LPA interviewed six (6) residents (R2-R7), and 6 out of 6 stated that they do have family members visit them, they all know if they have a roommate, they cannot have visitors inside their room. On, 12/03/24, between 12:00 pm – 2:00 pm LPA interviewed six (6) staff (S1-S6) all denied the allegation. The records reviewed, dated 09/30/2024, showed that most of the residents had visitors at the facility. During the visit to the facility on 12/03/2024, the department observed several family members visiting the residents some of them signed in, and some of them refused to sign in. Based on interviews, observations, and records reviewed, there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the Administrator Maria Bravo.