Complaint·June 13, 2022

Continued LIC9099-C page 2 Allegation #1 Staff are not following COVID-19 procedures: S1-S3 and R2-R6 interviewed stated staff is following COVID-19 procedures. If there are positive COVID-19 results all team members, residents, families, responsible parties, visitors, and appropriate agencies are notified immediately via letter. LPA observed the facility has an approved Mitigation Plan Report on file. Administrator Kelley Koul stated the facility is following the Mitigation and Infection Control Plan. S1-S3 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. Koul 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. Allegation #2 Staff are retaliating against residents: S1-S3 and R2-R6 interviewed stated staff does not retaliate against residents complaining about things at the facility. R2-R6 stated they are happy residing at the facility and their care needs are being met. R2-R6 stated staff is available to assist residents if there are any questions, issues, problems, or concerns. S1-S3 stated residents are assisted with their daily living, and staff is providing the necessary care and supervision to meet residents' needs Investigation revealed the following: Interviews were conducted with staff 1-3 (S1-S3), and residents 1-6 (R1-R6). S1-S3 and R2-R6 stated COVID-19 positive residents are not being kept in the room with COVID-19 negative residents. S1-S3 and R2-R6 stated that staff and residents are wearing masks. LPA Bunker observed staff and residents with their masks on during today's visit. The administrator stated staff is not going in and out of positive COVID-19 residents' rooms into negative COVID-19 residents' rooms. Ms. Koul stated if there is a positive COVID-19 resident they are assigned to a Med Tech. Ms. Koul stated the Med Techs give residents their medication and their COVID-19 tests. The caregivers deliver the food to residents. Ms. Koul stated all staff and residents are tested and notified if the test result is positive for COVID-19. Ms. Koul stated if a resident is out when the facility is doing mass COVID-19 testing the Med Techs will test the resident when they return back to the facility. Ms. Koul stated The facility is adequately staffed and the facility staff is trained, qualified, and competent to do their jobs and receives ongoing training. LPA reviewed the facility’s surveillance testing records. See continued LIC9099-C page 3 Continued LIC812-C page 3 LPA verified that the facility has an approved Mitigation Plan Report. Administrator Kelley Koul stated some of the staff and all residents are fully vaccinated. The facility has the ability to quarantine either non-symptomatic or positive COVID-19 residents. Ms. Koul stated the facility is following all guidance and direction regarding infection control protocol. Ms. Koul 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-S3 and R2-R6 stated staff does not retaliate against residents for complaining about things against the facility. S1-S3 and R2-R6 stated the allegations are false. Staff 1-3 (S1-S3) and residents 2-6 (R2-R6) interviewed all denied the 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 Administrator Kelley Koul. There were no deficiencies cited. An exit interview was conducted.