complaint·July 20, 2025

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 4 interviews (S1 – S4), Resident#1-10 (R1-R10), Interview of Orkin Pest Control Technician (W1), Orkin Pest Control Services Reports dated 01/2025 through 05/2025, Caregiver Response To Residents Care Log for the month of 06/2025, In-Service Training Logs for 01/2024 through 12/2024, In-Service Training Sign-in Sheet for 05/28/2025, Direct Care Orientation Training Checklist for staff#4 (S4), Dementia Care Staff Training for staff#3 (S3), and physical plant tour. The investigation revealed the following: regarding the allegation “Staff did not ensure the facility was free of pests.” It is alleged the facility has pests throughout the facility. Ten (10) out of the ten (10) residents interviewed corroborated this allegation. During record review, LPA Ramirez reviewed Orkin Service Report dated 05/28/2025, revealed Orkin pest technician documented “ Duster six units under refrigerator that I found massive German roaches and set up new monitors, and I suggested to (S2) to add a one more scope of service of month to get the issue under control (202, 210, 211, 223, 234, and 124).” Interview of S2 revealed the facility maintains monthly pest control services and on 05/28/2025, pest control technician did recommend to S2 that adding an additional service of pest controls services would help control the ongoing insect issues. S2 revealed to LPA Ramirez that the facility did not need an additional pest control services and that the staff would be placing more insect traps and would try to address the insect issues themselves. Interview with Administrator Mendibles, revealed the facility addresses the ongoing insect issues by treating the affected rooms themselves along with monthly pest control service. Orkin Service Report dated 01/31/2025, revealed pest control technician treated resident rooms #226, 227, 251, 233, 121, and 112. Orkin Service Report dated 02/28/2025, revealed pest control technician treated interior resident rooms# 234 and 235. Orkin Service Report dated 03/27/2025, revealed pest control technician treated resident rooms# 115, 206, 211, 226, 233, 238, and 251. During facility tour on 06/17/2025, LPA Ramirez observed live roaches in disposable roach glue traps in resident room#111. The facility has been receiving regular pest control services, and in addition, they have taken proactive steps to address the issue by applying pesticides themselves. However, despite these efforts, the presence of insects persists, suggesting that the current approach may not be working and the Orkin report dated 05/28/2025, reflects some of the same resident rooms that were treated in the past 5 months are still experiencing insects. Based on interviews, records reviewed and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . SEE 9099-C “Unqualified staff providing care to residents.” It is alleged that staff are not properly trained or certified to be caregiver. Four (4) out of the four (4) staff interviewed denied this allegation. Ten (10) out the ten (10) residents interviewed denied this allegation. During record review, LPA Ramirez observed Dementia Care Staff Training for staff#3 (S3) dated 03/01/2023 (does not reflect hours completed for each topic). LPA Ramirez reviewed and obtained In-Service Training Logs for 01/2024 through 12/2024 and In-Service Training Sign-in Sheet dated 05/28/2025. In-Service Training logs for 01/2024 through 12/2024 did not reflect required annual training hours and training topics on dementia, postural supports, restricted health conditions, and hospice care, as required by Title 22, Division 6, Health and Safety Code, Chapter 03.2 Residential Care Facilities for the Elderly, Article 06. Other Provisions- Staff Trainings 1569.62. LPA Ramirez observed various training including the following training's in for 2024: Shift Report-Elderly Needs dated 01/11/2024, Burnout dated 01/25/2024, Kitchen Safety dated 02/01/2024, Emergency Shut off dated 02/29/2024, Resident Right-Proper entry into resident rooms dated 03/13/2024, Mobility, Falls, and Dementia dated 06/27/2024, Postural Supports/ Dementia dated 10/24/2024, and change in condition dated 11/14/2024. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . Three (3) deficiencies were cited as result of this complaint investigation. Exit interview was conducted and a copy of this report was provided via email. A copy of this report, 9099-D and appeals rights was provided. The investigation revealed the following: regarding the allegation “Staff are not responding to residents call button in a timely manner.” It is alleged that staff are not responding to residents call button in a timely manner. Ten (10) out of the ten (10) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. LPA Ramirez tested call button in random rooms during facility tour and staff responded in a timely manner. Review of Caregiver Response To Residents Care Log for the month of 05/2025 and 06/2025, did not corroborate this 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 UNSUBSTANTIATED . Staff are not providing adequate food service to residents. It is alleged staff are not providing adequate food service to residents and making residents ill. Ten (10) out of the ten (10) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. LPA Ramirez toured facility kitchen and observed all refrigerators and freezers to be operational. LPA Ramirez did not observe spoiled or rancid food items on serving plates or in pantry. LPA Ramirez observed staff wearing gloves while handling food. During record review, LPA Ramirez did not observe incident reports that indicated residents became ill due to food provided by the facility. 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 . No deficiencies were cited for these allegations. Exit interview was conducted. A copy of this report was provided via email.