complaint·April 9, 2024

The investigation revealed the following: Allegation: Staff did not prevent resident from having access to illegal drugs. It is alleged that R2 smokes marijuana in the facility and consumes methamphetamines. This allegation was investigated by Investigations Branch (IB) investigator Canto which revealed the following: The staff members and residents that Cano interviewed stated some residents are known to smoke marijuana outside the facility but have not seen anyone use methamphetamines. R2 admitted to consuming methamphetamines (meth) while residing in the facility, and stated they obtained and consumed the meth off grounds and was never facilitated by the Downey Retirement Center (DRC) employees. Canto found no evidence to corroborate the allegation that facility staff members allowed the consumption/use of illegal substances at the facility. Allegation: Staff did not prevent residents from smoking inside the facility. It is alleged that R2 smokes marijuana inside R10’s bedroom. LPA’s toured facility both upstairs and downstairs, with some of the residents rooms doors open, and did not observe any odors of smoke. LPA’s reviewed Admission Agreement under “House Rules/General Facility Policies” there was a section that covered smoking policies and designated areas for smoking: “#2. Smoking in the facility, including balconies and courtyards, is strictly forbidden due to the health and safety risks to other residents and to facility staff”. Per S1 if a resident fails to comply with any of the house rules, that resident is spoken to and given a copy of the house rules, they must sign house rules and that copy is placed in resident file as a warning, if the behavior persists and they continue to break the rules continuously the resident is reassessed and sometimes transferred to a higher level of care if they are no longer fit for facility. Based on interviews with staff 5 out of 5 staff stated that they do not allow residents to smoke inside the facility, and that although they have never caught a resident smoking inside the facility when there is a heavy smoke smell present in their room or in an area that residents are, staff ask if they have smoked in the area and remind residents that if they are caught smoking inside the facility they risk being evicted. Based on interviews 2 out of 10 residents stated that they have never seen or heard of residents smoking inside the facility, that there are designated areas in the front and back of building for smoking, and that staff have told them where the designated areas are . S10 stated that they do not smoke and have never seen another resident smoking inside the facility. (Continued on 9099-C) Allegation: Staff did not prevent resident from making inappropriate comments towards other residents. It is alleged that R12 has offered to give residents a “blow job” for stuff (money/cigarettes). Based on interviews with staff 5 out of 5 staff stated that they were aware of R12’s comments and behaviors. S1 stated that R12 had been spoken to on many occasions and staff had been working on redirecting R12 to discontinue inappropriate comments to other residents, S1 further stated that R12 is no longer a resident at the facility and has since been transferred to a different facility for a higher level of care. LPA’s reviewed incident report dated 10/10/2023 that revealed R12 was sent to hospital for re-evaluation and was transferred out on 10/16/2023 to a facility for higher level of care. Based on interviews with residents 8 out of 10 residents stated that they have never seen/heard R12 make these inappropriate comments, however, R12 is no longer residing here and have not had these comments made to them by any other resident. Allegations: Staff did not prevent resident from engaging in inappropriate sexual behaviors (and) Staff did not prevent resident from engaging in inappropriate behaviors. It is alleged that R12 was masturbating in front of the facility. LPAs interviewed staff and 4 out of 5 staff stated that they have never seen or heard of this type of behavior or of the reported allegation. LPA’s asked if there are any cameras that may have covered this alleged area and S1 stated that the facility does not have any video surveillance. LPA’s interviewed 10 residents and 9 out of 10 residents stated that they have never heard about the reported allegations and have never seen/heard of a resident engaging in inappropriate sexual behaviors or inappropriate behaviors. Allegation: Staff did not prevent resident from hitting another resident. It is alleged that R1 and R9 got into a physical altercation where R1 got hit on the calf and stomach by R9. LPA’s reviewed SOC341 dated 8/21/23, the following parties were notified of the incident: Community Care Licensing, Law Enforcement, Local Ombudsman and Responsible Parties. Based on interview with R1, resident stated that staff were not around during time of incident of 8/20/23 and incident happened fast that once staff arrived the incident had de-escalated and there were no further occurrences after that, and resident did file a police report that day. Based on interviews with residents 8 out of 10 residents stated that they have not been in any physical or verbal altercations and feel staff would try their best to prevent any altercations between residents. Based on interviews with staff 5 out of 5 staff stated that there are typically never any physical altercations between residents, in the case that there are, staff will address the situation, separate the residents, speak to each one individually and monitor to ensure no further altercations arise. (Continued on 9099-C) Allegation: Facility is malodorous. It is alleged that it smells like feces upstairs for a long time. LPA’s toured facility both upstairs and down stairs and did not observe any feces odors at any point during tour. LPA’s interviewed 5 staff and 5 out of 5 staff stated that they have not observed any feces smell throughout the facility, however, the odor may happen in rooms with residents with incontinence issues or in passing from a resident who refuses to bathe. Staff stated that with multiple attempts of redirection they are able to have a resident agree to bathe so they no longer have that odor. Based on interviews with residents 7 out of 10 residents stated that they do not observe any odors of feces in the facility, 3 out of the 10 residents stated that although there had been moments where the odor was present it has gotten better and have not currently observed any feces odor. Based on statements and interviews conducted with staff and residents, review of client files and admission agreement/house rules, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations)did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided to Administrator Brandie Mendibles.