Inspector’s narrative
What the inspector wrote
Investigation Revealed the Following:
Allegation: Staff did not respond to residents’ requests for assistance in a timely manner.
The details of the complaint alleged that facility took a long time to tend to (R#2)’s call.
On May 21, 2025, at approximately 4:00 PM, during a records review, LPA Iniguez observed the Resident Incident Details Report for the period from April 1, 2025, to May 22, 2025. It was noted that in room 303, where (R#1 and R#2) reside, the maximum time recorded for facility staff response was 3 hours and 53 minutes on May 15, 2025, at approximately 6:58 AM. Additionally, on May 7, 2025, the time recorded was 1 hour and 43 minutes at approximately 8:28 AM. Furthermore, LPA Iniguez found that in room 304, the response time for facility staff was 2 hours and 50 minutes on April 10, 2025, at approximately 7:24 AM, and 1 hour and 6 minutes on May 6, 2025, at approximately 6:31 AM to clear the alarm.
On May 21, 2025, at approximately 10:00 AM, during an interview with the Administrator (A#1), she stated that the facility has a pull system, and the facility staff can hear who and where that alarm is coming from. Also, (A#1) stated that it takes approximately 10 minutes to tend to when a resident pulls the alarm. However, (A#1) stated that there have been times when facility staff take longer than 10 minutes to tend to the resident's alarm.
On May 21, 2025, at approximately 1:00 PM, during interviews with residents (R#1-R#7), (6) out of (7) stated that they had used the pull alarm system and noticed that the facility staff took longer than 10 minutes to come and assist them.
Evaluation Report continues LIC 9099-C
On May 21, 2025, at approximately 02:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that stated that when it comes to a resident pulling the alarm cord, it takes them approximately 10 minutes. However, (5) out of (5) facility staff stated that there have been times when they have taken more than 10 minutes to help the residents.
During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.
Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be
SUBSTANTIATED.
California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.
An exit interview was conducted, and a copy of the Complaint Report was given to Monique Avila/Wellness Director.
Investigation Revealed the Following:
Allegation:
Staff did not ensure resident’s monitoring device was properly placed.
The details of the complaint alleged that (R#1)’s monitoring device is not placed by their bed side.
On May 21, 2025, at approximately 3:00 PM, during a records review, LPA Iniguez observed (R#1) ’s Service Plan dated 4/25/25. The plan states that (R#1) is a fall risk, and the facility staff needs to assist them using assistive devices and monitoring due to non-compliance.
On May 21, 2025, at approximately 4:00 PM, LPA Iniguez physically inspected (R#1)’s room. LPA Iniguez observed a motion sensor device by the TV stand that faces (R#1)’s bed. LPA Iniguez asked facility staff to test the motion sensor, and LPA Iniguez observed that it was working properly.
On May 21, 2025, at approximately 11:30 AM, they stated that they had always seen that monitor device there during an interview with (R#1) in their room.
On May 21, 2025, at approximately 10:00 AM, during an interview with the Administrator (A#1), she stated that (R#1) has a sensor device that allows the facility staff to notice when (R#1) gets in bed or out. In addition, (A#1) stated that the facility staff checks on (R#1)’s monitor devices as needed.
On May 21, 2025, at approximately 02:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that (R#1) has a monitor device that tells them when (R#1) moves. In addition, (5) out of (5) facility staff stated that they check on (R#1)’s monitor device as needed.
Evaluation Report continues LIC 9099-C
During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).
Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be
UNSUBSTANTIATED.
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.
An exit interview was conducted, and a copy of the Complaint Report was given to Monique Avila/Wellness Director.
