Complaint·May 28, 2025

Allegation #1: Staff left residents in soiled diapers for a long time. This complaint alleges 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 seven (7) residents #1-7 (R1-R7). 6 out of 7of 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 an 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 attempted to interview R1, who declined to answer any of the questions asked. 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. Allegation #2: Staff did not ensure that residents were fed. This complaint 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 door and ask if the residents want to have 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 seven residents #1-7 (R1-R7). 6 out of 7 denied the allegation and stated that the facility would go to their room and knock 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. Report continued LIC9099-C 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 Richard attempted to interview R1, who declined to answer questions when asked. 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. Allegation #3: Staff verbally abused the resident in care. This complaint alleges that the facility staff 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 that the staff ever verbally abused 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 seven (7) residents (R1-R7), 6 out of 7 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 received training regarding clients’ rights. LPA attempted to interview R1, who declined to answer any of the questions asked. 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 continued LIC9099-C Allegation #4: Staff threw the resident's personal belongings. This complaint alleges 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, and 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 seven (7) residents #1-7 (R1-R7). 5 out of 7 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 the facility staff threw away their stuff. LPA attempted to interview R1, who declined to answer any of the questions asked. 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. Allegation #5: Staff made a false report about a resident in care. This complaint alleges 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 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 seven (7) residents #1-7 (R1-R7), and 6 out of 7 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. Report Continues, see LIC9099C LPA Richard attempted to interview R1, who declined to answer any of the questions asked. 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. Allegation #6: Staff prevented the resident from having a visitor in care. This complaint alleges that the staff is not allowing the residents' visitors to visit the 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, they 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 deny them entry. On 12/03/24, between 10:30 am -12:00 pm, LPA interviewed seven (7) residents (R1-R7), and 6 out of 7 stated that they do have family members visit them; they all know that if they have a roommate, they cannot have visitors inside their room. On 12/03/24, between 12:00 pm and 2:00 pm, LPA interviewed six (6) staff (S1-S6), all denied the allegation. LPA Richard attempted to interview R1, who declined to answer any questions asked. 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 Assistant Administrator Jesus Chavez.