Inspector’s narrative
What the inspector wrote
The investigation revealed the following:
Allegation:
Facility failed to maintain a complete and accurate resident’s records.
The allegation alleges that the facility has incomplete resident records.
During the facility file review LPA reviewed and received copies of required documents to maintain for Residents. LPA reviewed six (6) Resident files, three (3) out of the six (6) Resident files had the required documents. During file review LPA observed the following documents were missing: Resident R2 was missing the Appraisal, Needs and Service Plan, and Safeguard for Property/Valuables. Resident R3 was missing the Appraisal, Needs and Service Plan, TB test, and Safeguard of Property/Valuables. Resident R4 was missing a Physicians Report and TB test. Interviews with Staff S1 and S2, two out of two stated they do not handle the Residents files, that the Administrator is responsible for making sure they have the required documents.
Based on LPAs observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number8), are being cited on the attached LIC 9099D.
An exit interview was conducted with House Manager, Rickey Bernal, and a copy of this report and the Appeal Rights were provided.
Allegation
Facility is in disrepair.
The allegation alleges that the facility is in disrepair.
LPA interviewed S1-S2, two out of two stated the facility is not in disrepair. S1 stated there is a maintenance person who comes in and makes repairs as needed. Dring interviews with Resident’s R1-R6, six out of six stated the facility is not in disrepair and they have no complaints about their accommodations. LPA toured the facility and observed it to be well-maintained. All rooms, bathrooms, and the exterior were checked and found to be compliant with Title 22 regulations. During the course of the investigation, LPA was unable to find any evidence supporting the allegation.
Based on interviews and observations, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.
Allegation:
Facility failed to maintain complete and accurate staff records.
The allegation alleges that the facility has incomplete staff records.
During the facility file review LPA reviewed and received copies of the required documents to be maintained in the staff files. LPA reviewed four (4) staff files (S1-S4), four out of four files had the required CCL documents including Personnel Record, Fingerprint Clearance, Criminal Record Statement, Health Screening, TB test, Employee Rights, Elder Abuse Index, First Aid/CPR Certificate, Education Verification, Medical Training and Staff Training Logs. During the course of the investigation, LPA was unable to find any evidence supporting the allegation.
Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.
An exit interview was conducted with Licensee, Albert Pimentel, and a copy of this report was provided.
Allegation:
Facility staff failed to properly administer resident’s medication
The allegation alleges that there have been medication errors.
During record review, LPA reviewed residents Medication Administration Records (MARs) and medications for six residents. Six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records. LPA interviewed Staff (S1 & S1) two out of two staff stated they receive training annually for medication administration. LPA interviewed five Residents (R1-R6), and six (6) out of six (6) residents stated they receive their medications daily and on time. During the course of the investigation, LPA was unable to find any evidence supporting the allegation.
Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.
Allegation:
Facility is not adequately staffed
The allegation alleges that facility is insufficiently staffed.
During interviews with Resident’s (R1-R6), six (6) out of six (6) stated they receive assistance when needed and have not had to wait to receive assistance. Additionally, six (6) out of six (6) stated the facility has enough staff to provide care to the residents. During interview with Staff (S1-S2) two (2) out of two (2) stated they are able to provide care to residents as needed. Additionally, Staff stated there are two (2) staff on during the day and evening shift, and one on the night. Staff S2 stated additional staff would be useful. S1 stated if they require additional assistance, they can call the administrator and either they would come and help or they send staff from another location to come and assist. During the time of visit, LPA observed all resident cares being met, the residents did not have to wait before they received assistance. LPA reviewed the Staff Roster and observed there are four (4) staff and administrator who work regularly. During the course of the investigation, LPA was unable to find any evidence supporting the allegation.
Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.
