complaint·December 8, 2021

The investigation revealed the following: Regarding the allegation, "residents bathroom is not properly cleaned" it was alleged that resident bathrooms are not thoroughly cleaned due to housekeeping not mopping floors and cleaning the toilets. Interviews with residents revealed: nine (9) out of eleven (11) residents stated that bathrooms are thoroughly cleaned including cleaning sinks, toilets, showers, and mopping. Two (2) out of eleven (11) residents stated that bathrooms are not thoroughly cleaned. Interviews with staff reveal that housekeeping staff cleans the toilets, take out the trash, mop, sweep, wipe sinks, and clean the tubs. Housekeeping staff stated that if residents request something to be cleaned again the staff will do it. They stated that resident rooms and bathrooms are checked daily and cleaned at least once a week. The assistant administrator stated that she hasn't heard of any residents complaining about this issue. A review of the housekeeping duties list reveal that housekeepers are required to mop floors and clean fixtures in the restroom. During the tour of the physical plant on 10/13/21, LPA observed that all resident's bathrooms appeared clean including floors, toilets, showers, and sinks. Regarding the allegation, "Staff did not change resident's bed linens in a timely manner," interviews with residents revealed: ten (10) out of eleven (11) residents interviewed stated bed linens are changed in a timely manner and that housekeeping changes the sheets several times per week and as needed when they are soiled. One (1) out of eleven (11) residents interviewed stated that bedding Is changed too late in the day. Housekeeping staff interviewed stated that bedding is changed at least 1-2 a week and whenever it is soiled. Bedding is checked daily during housekeeping rounds and are changed more frequently if needed. Staff denied the allegation. During the tour of the physical plant on 10/13/21, LPA observed that all resident's bedding was clean. Regarding the allegation, “Resident was put on a 72 hour hold without cause” it was alleged that a resident was forced to leave the facility on a psychiatric hold for no legitimate reason. Interviews with the S5-S6 who were involved in the incident indicated that the resident was a danger to himself and others which is why a 72-hour hold was placed. S5 stated that R1 was had been drinking and was being aggressive with staff and residents and refusing to take psychiatric medications. S5 called the psychiatrist who approved the 72-hour hold and the Downey Police Department were called to assist. LPA obtained the police incident report dated 9/14/21 which stated that R1 was upset with roommate and was “non-compliant and being aggressive towards staff.” R2 stated that, during the incident, R1 was arguing and yelling at staff and refusing to take his medications. There were no other resident witnesses involved and all other residents interviewed did not have details about the incident. Other staff interviewed did not have knowledge of the incident. A review of incident report dated 9/15/21 states that R1 was being non-compliant and aggressive towards staff and facility staff called psychiatrist who ordered the 72-hour hold. The psychiatrist was unable to reached by LPA for interview. ***Continued on LIC9099C*** Based on interviews, observations, and records reviewed, it is determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with the assistant administrator Cynthia Flores and copy of report was provided. The investigation revealed the following: Regarding the allegation, “staff did not safeguard resident’s personal belongings,” interviews with residents revealed: eight (8) out of eleven (11) residents stated that they have items missing or stolen from their room. Three (3) out of eleven (11) residents stated that they have not had anything missing or heard of any other residents with this issue. Residents with missing items stated that when they informed the staff, nothing was done about it. Staff interviewed stated that they have not heard of any residents complain about stolen or missing items. The assistant administrator stated that resident inventory is taken upon admission unless they opt out. She stated all resident rooms are locked unless they leave the door open. A review of the admissions agreement theft and loss policy states that items reported lost or stolen will be replaced or reimbursed. A review of R1’s inventory list reveals that the items allegedly missing were not listed on the form. Staff notes indicated that facility staff packed up resident’s items upon move out but R1 refused to sign the move-out inventory list. During the physical plant tour on 10/13/21, LPA observed that R1’s antennae was found under the bed. The other missing items were not found during the tour. Regarding the allegation, “staff did not provide adequate food service,” it was alleged that hot meals are served to residents cold/luke warm and service takes too long. Interviews with residents revealed: nine (9) out of eleven (11) residents interviewed stated that meals are served luke warm or cold and the wait times for meals are at least one (1) hour. Two (2) out of eleven (11) residents interviewed stated that the food is served at an adequate temperature and wait times are not too long. Dietary staff interviewed stated that meals are served to residents right away and those who get foods delivered to their room have their food saran-wrapped to keep it warm. The assistant administrator stated that she has had no complaints regarding food service. A review of the menu reveals that residents are served with a variety of foods. LPA Spencer observed meal service during the visit on 10/13/21. LPA observed that residents with tray service had their food plated at 11:37 a.m. and the last resident received their plate at 12:27 p.m. (50 minute wait time). During lunch time in the dining room, LPA observed that residents were seated in the dining room at 12 p.m. and the first table was served their food at 12:45 p.m. (45 minute wait) while the last table was served their food at 1:13 p.m. (73 minute wait time). ***See LIC9099C for continuation of this narrative*** Regarding the allegation, “staff withheld residents mail” it was alleged that staff do not provide residents with their mail in a timely manner. All residents interviewed stated that they must inquire about their mail and are not informed when mail comes for them. The assistant administrator stated that mail is sorted by herself or the front desk staff and they put in a file folder. She stated that residents usually call or come down to pick up their mail. LPA observed the file folder located in the front office which had mail still placed in it. In R1’s file, a copy of a UPS letter marked “return to sender” was observed. Assistant administrator stated that residents are not delivered the mail to their rooms but will call to inquire about their mail or come down to get it. Other staff interviewed were not aware of this issue. Based on observation, interviews, and records reviewed the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Pursuant to Title 22, deficiencies cited on the attached 9099D. An exit interview was conducted with the assistant administrator and a copy of the report and appeal rights were provided.