complaint·May 12, 2023

Continued LIC9099-C page 2 Allegation #1: Staff did not follow COVID-19 Protocol. S1-S2 and R1-R7 interviewed stated staff is following COVID-19 protocol and procedures. If there are positive COVID-19 results all team members, residents, families, responsible parties, visitors, and appropriate agencies are notified immediately. LPA observed the facility has an approved Mitigation Plan Report and Infection Control Plan on file. Executive Director Rita Meldonian stated the facility is following the Mitigation and Infection Control Plan. S1-S2 stated the facility will call the resident's family, and send email letters, the residents are notified door to door with a memo letter, and it is posted at the receptionist desk and throughout the facility if a resident or staff test results are positive for COVID-19. Ms. Meldonian stated everyone is notified if there is a positive COVID-19 case. If staff and residents had any questions staff is available to answer questions. S1-S2 stated that in April 2023, staff did not take a bag filled with needles and medication into the kitchen amongst food, then spilled the contents unto the lettuce and other food items. S1-S2 stated twelve (12) residents did not contract COVID-19. S1 stated one resident was hospitalized it was not from contracting COVID-19. That resident was in the hospital for something else, and it had nothing to do with COVID-19. That resident is back at the facility and is doing well. S1 stated the facility had one (1) COVID-19 case in January 2023 and two (2) in March 2023, which was reported to Community Care Licensing and all the appropriate agencies in a timely manner. Allegation #2: Staff does not meet residents' dietary needs. Staff 1-2 (S1-S2) and residents 1-7 (R1-R7) stated staff is meeting the resident's dietary needs if a resident is on a special diet. S1-S2 stated that modified diets prescribed by a resident's physician as a medical necessity are provided. S1-S2 and R1-R7 stated that on the Easter Holiday, there was not only one (1) caregiver working at the facility, providing care and supervision to 85 residents. S1-S2 stated the facility does not have 85 clients in placement. S1-S2 and R1-R7 stated the facility is fully staffed and the facility did not have insufficient staffing on Easter. S1-S2 and R1-R7 stated residents ate their meals in the dining room and did not have to eat their meals in the rooms. S1-S2 stated that the facility is not insufficiently staffed, and residents residing in the memory care unit are receiving their meals. S1-S2 stated that Memory Care Coordinator Erica Juarez handles the Memory Care Unit. S1-S2 stated the caregivers working in the Memory Care Unit do not make decisions for the residents if there is a problem staff will report the incident. S1-S2 and R1-R7 denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation #3: Staff does not prevent unauthorized persons from entering the facility. Staff 1-2 (S1-S2) and residents 1-7 (R1-R7) interviewed stated unauthorized people are not allowed in the facility. S1-S2 and R1-R7 stated visitors check in at the front desk before they can visit residents and sign in before entering. S1-S2 and R1-R7 stated unauthorized people from the street do not enter the facility during all hours and do not break into residents' rooms. S1-S2 and R1-R7 stated unauthorized people do not enter the facility through the facility's entrance door without checking in. S1-S2 and R1-R7 stated the facility entrance does not remain unlocked. S1-S2 and R1-R7 stated the facility doors are not left open and are closed during certain hours. S1-S2 and R1-R7 stated the facility has 24-hour surveillance cameras. S1-S2 and R1-R7 denied the allegation. Allegation #4: Staff does not communicate with the resident, nor authorized representative regarding the resident's care . Staff 1-2 (S1-S2) and residents 1-7 (R1-R7) stated staff does communicate with resident and their authorized representatives regarding residents' care. S1-S2 stated staff communicates with residents' family members and representatives monthly or as often as needed. S1-S2 stated staff communicated with resident representatives in person, via telephone, and emails and replied to their concerns promptly and appropriately. LPA Bunker observed the once-a-month progress notes with communication and documentation with an authorized representative. S1-S2 and R1-R7 denied the allegation. Investigation revealed the following: Interviews were conducted with staff 1-2 (S1-S2), and residents 1-7 (R1-R7) stated the facility is following COVID-19 Protocol. LPA verified that the facility has an approved Mitigation and Infection Control Plan Report. The facility has the ability to quarantine either non-symptomatic or positive COVID-19 residents. S1 stated the facility is following all guidance and direction regarding the Mitigation and infection control protocol. S1 stated that whenever they receive a positive COVID-19 test result it is reported to all the appropriate agencies, Community Care Licensing, Los Angeles County Department of Public Health, resident's families, responsible parties, staff, residents, and visitors are notified immediately. S1- S2 stated The facility is adequately staffed and the facility staff is trained, qualified, and competent to do their jobs and receives ongoing training. During the visit, LPA Bunker observed adequate staff working and assisting residents in care. S1-S2 and S1-S7 stated staff does meet residents' dietary needs. See continued LIC9099-C page 4 Continued LIC812-C page 4 S1-S2 stated that modified diets prescribed by a resident's physician as a medical necessity are provided. S1-S2 and R1-R7 interviewed stated unauthorized people are not allowed in the facility. The facility has 24-hour surveillance cameras to see who enters and exits the building. S1-S2 and R1-R7 stated staff does communicate with resident and their authorized representatives regarding residents' care. S1-S2 stated staff communicated with resident representatives in person, via telephone and emails, and replied to their concerns promptly and appropriately. LPA Bunker observed the once-a-month progress notes with communication and documentation with the authorized representative. S1-S2 and R1-R7 denied all allegations. Based on interviews, available evidence, observation, information received, 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. A copy of the Complaint Investigation Report LIC 9099 and LIC9099-Cs, was provided to Executive Director Rita Meldonian There were no deficiencies cited. An exit interview was conducted.