complaint·January 6, 2025

The investigation revealed the following: Allegation: Staff physically abused resident. It was alleged that a resident was physically assaulted while in care. It is also being alleged that a resident was pushed out the facilities front door. On 11/21/24, the department interviewed S1-S8 and R1-R9. Based on interviews conducted, eight (8) out of eight (8) staff interviewed said they do not know or recall of an incident where a resident was pushed out the front door. Five (5) out of eight (8) staff interviewed revealed that a resident was physically assaulted while in care back in October 2024. An interview conducted with S7 revealed that a resident was physically assaulted by a staff member on 10/02/24 and that employee had been terminated. Based on interviews conducted, six (6) out of nine (9) residents interviewed said they did not know of an incident involving a staff member physically assaulting a resident. Records review of an Unusual Incident/Injury Report dated 10/03/24, and discharge paperwork from St. Mary Medical Center-Long Beach revealed that on 10/02/24, a caregiver had physically assaulted a resident, and emergency services were called. St. Mary Medical Center discharge paperwork revealed that R4 was seen on 10/02/24 for a facial injury. The discharge diagnosis was blunt trauma, abrasions of multiple sites, and subconjunctival hemorrhage. Based on observation, interviews conducted, and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Allegation: Staff was under the influence while caring and supervising resident. It was alleged that a med-tech was sent home after being under the influence while administering medication. Based on interviews conducted, five (5) out of eight (8) staff interviewed revealed that they knew of a med-tech being under the influence while administering medication. An interview with S7 revealed that a other staff reported to management that a med-tech was under the influence. That staff member then admitted to being under the influence and was sent home and terminated. Based on interviews conducted, five (5) out of nine (9) residents interviewed said they did not know of an incident involving a staff member being under the influence while administering medication. Records review of an Unusual Incident/Injury Report dated 10/31/24 revealed that on 10/29/24, an employee admitted to being under the influence while at work. The employee was removed from the building and terminated. Based on observation, interviews conducted, and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Quality Assurance Director, Melissa Flores, and a copy of the report and appeal rights was provided. The investigation revealed the following: Allegation: Staff are not properly documenting resident's medications when administered. It is alleged that the MARs are incorrect and are being tampered with. On 11/21/24, the department interviewed S1-S8 and R1-R9. Based on interviews conducted, eight (8) out of eight (8) staff interviewed stated that the MARs are correct. Eight (8) out of eight (8) staff interviewed stated that the MARs have not been tampered with by staff. Based on interviews conducted, seven (7) out of nine (9) residents interviewed said that staff administers their medication daily and on time. Seven (7) out of nine (9) residents interviewed revealed that they don’t know if the MARs are incorrect or if they have been tampered with. On 01/06/25, the department reviewed MARs for the month of October 2024 and November 2024 and observed the MAR’s to be complete and in order. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the allegation mentioned above. 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. Allegation: Staff do not ensure resident's showering needs are being met. It is alleged that residents are not showering. Based on interviews conducted, eight (8) out of eight (8) staff interviewed stated that resident’s follow a shower schedule. Eight (8) out of eight (8) staff interviewed stated that the resident’s shower 2-3 times a week. Based on interviews conducted, seven (7) out of nine (9) residents interviewed said that they do shower. Seven (7) out of (9) residents interviewed revealed that staff ensure their showering/hygiene needs are being met. Seven (7) out of nine (9) residents interviewed revealed they are satisfied with the services being provided by staff at this facility. Continued on LIC809-C A review of records, of the resident's Shower Schedule revealed that the residents are scheduled to at least two (2) showers a week. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the allegation mentioned above. 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. Allegation: Staff do not ensure resident's health care needs are being met. It is alleged that staff is not checking resident’s blood pressure before administering medication. It is also being alleged that hospice residents do not get food and that the resident’s don’t get physical therapy. Based on interviews conducted, eight (8) out of eight (8) staff interviewed stated that staff ensures to check resident’s blood pressure if and when needed. Eight (8) out of eight (8) staff interviewed said that residents are provided three (3) meals a day, and snacks in between. Eight (8) out of eight (8) staff interviewed revealed that all residents who require physical therapy get it as scheduled. Eight (8) out of eight (8) staff interviewed stated that they make sure that the residents care needs are being met daily. Based on interviews conducted, five (5) out of nine (9) residents interviewed said that they don’t get their blood pressure checked because they don’t need it. Seven (7) out of nine (9) residents interviewed said that they are provided three (3) meals a day along with snacks. Seven (9) out of (9) residents interviewed revealed that they are satisfied with the services being provided by staff at the facility. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the allegation mentioned above. 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. Continued on LIC809-C Allegation: Staff do not have a background clearance. It is alleged that employees do not have clearance to work at the facility. Based on interviews conducted, eight (8) out of eight (8) staff interviewed stated that they had background clearance before they started working at this facility. Based on interviews conducted, six (6) out of nine (9) residents interviewed said that they do not know if the employees have background clearance. The department reviewed the facility's staff roster and compared it to the Facility Personnel Report Summary (LIS536) that was printed on 11/19/24 by the department and revealed that all employees listed on the staff roster provided to the department matched the LIS536 and staff listed had an associate status listed as cleared. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the allegation mentioned above. 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. An exit interview was conducted with Quality Assurance Director, Melissa Flores and a copy of the report and appeal rights was provided.