complaint·February 27, 2025

The investigation revealed the following: Allegation: Licensee does not ensure facility is adequately staffed to meet resident's needs. It was alleged that the facility is not meeting the resident’s needs adequately due to the facility not being adequately staffed. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 states the facility has about 34 staff and is adequately staff even with the agency that the facility uses. On 12/16/2024 between 11:45am - 1:00 pm, 1/21/25 2:48pm and 1/24/25 at 9:05 am, LPA/LPM interviewed Staff #1-7 regarding the allegation; 3 out of 7 staff confirmed the allegation facility is not adequately staffed, 4 out of 7 staff denied the allegation and feel the facility is adequately staffed. On 12/16/2024 between 10:00am - 11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 4 out of 10 residents confirmed the allegation; 6 out of 10 residents denied the allegation. LPA reviewed and observed on the Personnel Report LIC 500 and Timesheets Personnel Report that the following 10 Care Partners, 3 Med Techs (who work as Care Partners as well), 1 LVN, 1 Executive Director, 1 Office Manager, 1 Intake Coordinator, 2 Front Desk Staff, 2 Activity Director, 6 Housekeepers, 1 Maintenance Staff (who also serves as a medtech as well). The facility also utilizes a Home Care Organization, Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. Allegation: Staff are not properly trained It was alleged that the facility has not properly trained their staff. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied the allegation as she states the training process consist of the use of care and compliance for 40 hours of annual training, video training (20 hours), onboard training (30 days) and continued training as needed (8 hours on site). On 12/16/2024 between 11:45am - 1:00 pm, 1/21/25 2:48pm and 1/24/25 at 9:05 am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 6 out of 7 staff interviewed denied the allegation; 1 out of 7 staff did not answer the question. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 4 out of 10 residents interviewed confirmed the allegation; 6 out of 10 residents denied the allegation. On 12/19/2024, LPA received documented staff training conducted in 2024 and observed the following training completed for 9 out 9 staff: new employee 20 hour video training, OSHA Bloodborne Pathogen Training 30 Mins, Basic Medication Training, Medication Technician (8 Hours), Annual Training (2 Hours) 4 Quarter Dementia Topics: Dementia Care: Aggressive Behaviors, Therapeutic Interventions, California Medication Regulations, Workplace Violence and Home Care Organization. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. Allegation: Staff did not properly assess residents prior to admission. It was alleged that the facility does not conduct a pre placement assessment of residents prior to them being admitted to the facility. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied the allegation of residents not being assessed prior to admission. On 12/16/2024 between 11:45am -1:00 pm, 1/21/25 2:48pm and 1/24/25 a, LPA/LPM interviewed staff regarding the allegation; 5 out of 6 staff interviewed denied the allegation; 1 out of 6 staff interviewed were unable to answer the question. On 12/16/2024 between 10:00am -11:30am and 1/21/2025 8:47am-9:38am LPA/LPM interviewed residents #1-10 regarding the allegation 8 out of 10 residents interview denied the allegation; 1 out of 10 residents confirmed the allegation; 1 out of 10 residents was unable to answer the question. LPA conducted a file review of 10 resident records. 10 of 10 records reviewed contained proper admission documents. Based on the records reviewed, interviews conducted and Observations the allegations are Unsubstantiated : 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 with Rafeal Silva, Quality Assurance Director and a copy of this report was provided.