complaint·December 31, 2024

Allegation: Staff do not report incidents to residents' responsible parties. It is being alleged that the facility consistently fails to report fall incident or notify families of their loved ones' deteriorating conditions. On 12/04/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 3 of 3 residents interviewed denied the allegation and denied experiencing a fall or injury while in care. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA facility did notify POA of fall as R1 was being transported to hospital by ambulance. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/04/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported S1 will review the written report before faxing it to CCLD and obtaining a fax confirmation number. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPA Villegas interviewed S2-S7 regarding the allegation above, 3 of 6 staff interviewed denied the allegation above and reported documenting when responsible parties are notified in the communication folder, 3 of 6 staff interviewed stated being unaware of the reporting procedures are after incidents are reported to the med room staff on shift. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided. Allegation: Staff do not administer medications as prescribed. It is being alleged medications are frequently administered late or improperly. On 12/04/24 LPA Villegas interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported documenting if there is a medication error. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPAs Espana and LPA Villegas interviewed S2-S7 regarding the allegation above 3 of 6 staff denied the allegation above, 3 of 6 staff interviewed reported they do not assist with medication therefore are unaware of the medication administration process. On 12/04/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 2 of 3 residents interviewed denied the allegation above, 1 of 3 residents interviewed reported not taking any medications. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA facility did not administer antibiotics are prescribed to R1. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/31/24 at 11:30am LPA Villegas conducted review of MAR for 4 residents, LPA Villegas observed that the MARs weren’t checked off and observed med tech was checking off meds that were passed during the AM during the review. On 12/31/24 1 of 7 overall staff interviewed disclosed medications errors are currently being worked on in order to correct discrepancies previously cites by LPA Brown on 12/10/24 and LPA Iniguez on 12/16/24. Allegation: Staff are not properly trained. It is being alleged that the facility has staff members who fail to complete mandatory annual training. On 12/04/24 LPA Villegas interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported training is ongoing. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPA Villegas interviewed S2-S7 regarding the allegation above, 1 of 3 staff denied the allegation above and reported shadowing for 2 weeks, 1 staff reported shadowing for 1 week, 1 staff reporting not having much training, and 3 of 6 staff reported training is upon hire with in-services as needed. On 12/04/24 between 9:30am-1pm LPA Villegas conducted interviews with (R3-R5) regarding the allegation above, 3 of 3 residents interviewed denied the allegation above and reported feeling safe when assisted by staff. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA all the “good caregivers” are no longer employed at the facility. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/31/24 LPA Villegas conducted a review of training records for 3 caregivers and observed completed required trainings in the personnel file. On 12/31/24 LPA requested copies of training for 3 meds techs however, LPA was not provide with training and was informed there is not documented training's for med techs on file. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8)are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.