complaint·September 13, 2023

Allegation: Illegal Eviction At 8:00 am LPA reviewed documentation from past visit(s) 08/15/2023 and 08/28/2023, namely, Staff 1-4 (S1-S4) who were interviewed as S1 had no knowledge of the eviction and referred to case manager (unknown name) and complainant, as being all called and informed. LPA spoke to S1 regarding the alleged illegal eviction. The Administrator stated R1’s POA and case manager were informed. The Administrator further stated R1 was not evicted because R1 had higher level of care requirements. S1 stated there was no eviction issued. LPA noted two different statements on 08/15/2023: (1) Administrator did speak with R1’s POA and case manager about relocating R1 and (2) the Administrator did not provide an eviction notice. Residents 1, 2, 3, 5, 6, 7 (R1-R3 and R5-R7) all have dementia and are nonverbal. Resident 4 (R4) is verbal. LPA on 08/28/2023 and 09/13/2023 did not observe an eviction notice(s) copy as requested. LPA on 08/28/2023 and 09/13/2023 did not observe unlawful detainer action from the Superior Court. LPA on 08/28/2023 and 09/13/2023 observed no written judgment. LPA on 08/15/ 2023 and 08/28/2023 requested from S1 medical discharge, medical records, hospice records, and facility log notes relating to higher level of care (e.g., stage 1, 2, 3, and 4 confirmations of higher level of care). Allegation: Staff did not observe resident had open wound It’s being alleged the facility has not observed “Staff did not observe resident had open wound.” 6 out of 6 residents interviewed goes as follows: Residents 1, 2, 3, 5, 6, 7 (R1-R3 and R5-R7) all have dementia and verbal (Classified: As verbal by S1. LPA could not interview R1-R3 and R5-R7 all have dementia and are classified as "Alert and oriented x1 to name" as referenced by the appraisal/needs and services plan LPA reviewed R2). 4 out of 4 staff denied the allegation, S1-4 denied observing “Staff did not observe resident had open wound.” 1 out of 1 Witness 1 (W1) agreed with the allegation ““Staff did not observe resident had open wound.” Allegation: Staff did not disclose to POA resident's health condition. Regarding the allegation: “Staff did not disclose to POA resident's health condition.” Based on LPA’s observations, interviews with S 1-4 and record reviews, and W1 interviews goes as follows: S1-4 that that facility resident family members/responsible party were notified of all changes relating to resident’s health condition. S1, informed the LPA that all changes of resident’s health were discussed with POA and documented in their case file. S1 also stated that S2-4 makes sure that family members are notified and also arrange for medical appointments. In addition, S1 and S2 inform family of resident incidents that occur in the facility in person, however, not in written form. According to S1 and S2 there has never been an issue with a resident’s family member not being notified of changes to a resident’s condition. According to S1 and S2 the POA was spoke to weekly or biweekly regarding changes of resident’s conditions. Due to R1 terminal illness, W1 provided documentation to the LPA about the assessment process for R1 (placement ending date: 06/12/2022). LPA confirmed that between June 12, 2021, and April 20, 2022, according to W1, that R1 obtained care from Good Hands Homecare. In addition, on May 22, 2022, per W1, R1 was taken to the Torrance Memorial Hospital to treat her injuries. W1 noted that R1 had been taken to Dignity Hospice. W1 stated R1 was in COVID isolation at the Downey Community Health Center. On June 16, 2022, R1 was transferred to the Sunny Day Guest Home, where medical professionals and caregiver detected lesions in the second stage of their development. R1 passed away on August 21, 2022. 6 out of 6 residents interviewed goes as follows: Residents 1, 2, 3, 5, 6, 7 (R1-R3 and R5-R7) all have dementia. LPA could not interview R1-R3 and R5-R7 all have dementia. 4 out of 4 staff denied the allegation, S1-4 denied observing “Staff did not disclose to POA resident's health condition.” 1 out of 1 Witness 1 (W1) agreed with the allegation “Staff did not disclose to POA resident's health condition.” Based on interviews conducted, record reviews and observation, the preponderance of evidence standard has not been met. 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. A copy of this report was provided and discussed and left with Licensee Administrator Michelle Porca whose signature on this form confirm receipt of these documents.