Complaint·October 17, 2024

Prior to today’s visit LPA interviewed a 4 th witness, whom shall be referred to as W4. LPA also received photos of the resident #1. The investigation reveals the following: " Staff is not keeping the facility clean and sanitary”. It is alleged the facility is not clean and sanitary. The administrator, denied the allegation stating staff always keep the facility clean. 1 out of 1 staff confirmed the administrator's statement. 3 out of 4 residents interviewed stated the facility is clean. 3 out of 4 witnesses stated when they visit the facility it is clean and neat. LPA observed that the facility was neat, clean, and without odor during the visit. Based on LPA's interviews, investigation revealed: 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. Exit Interview Conducted with Administrator via phone/ A Copy of the Report Issued. The investigation reveals the following: " Resident sustained excoriation of the skin due to lack of care from staff”. It is alleged the R1 is in prolonged moisture. During the visit, the Administrator denied the allegation stating that R1 is changed as needed and refuses assistance from care staff. LPA asked the Administrator if they placed double briefs on R1, and the Administrator confirmed with S1 that they did not. 1 out of 3 residents stated they receive assistance to the restroom as needed. 1 out of 3 residents confirmed staff leave them sitting in urine. LPA Baptiste received photo proof of the resident's distended brief and confirmed via photos the resident was wearing double briefs. According to W4, R1’s excoriation was improving, but due to the excess moisture, R1’s excoriation worsened, which prompted W4's home health agency to be worried about the progression of R1 excoriation. LPA received photos of the excoriations and observed the worsening of R1's excoriations. The investigation reveals the following: " Staff is not meeting resident's toileting needs”. It is alleged that R1 sits in feces and urine. During the visit, the Administrator denied the allegation stating R1 is a difficult resident and has contacted the physician. 1 out of 3 residents confirmed they receive assistance to the restroom as needed. 1 out of 3 residents confirmed staff left them sitting in urine and feces. The resident further stated at night staff is not around to change them, but in the daytime, they are changed. LPA Baptiste received photo proof of the resident's distended brief and confirmed via photos the resident had dried feces on there hands. The investigation reveals the following: " Staff is not meeting resident's hygiene needs”. It is alleged that R1 was eating with dried feces on their hands. During the visit, the Administrator denied the allegation. 1 out of 3 residents stated they receive assistance to the restroom as needed. 1 out of 3 residents confirmed there were three (3) times feces was on their hands. The home health agency confirmed the allegation. LPA Baptiste received photo proof of dried feces covered on the resident’s hands. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview Conducted with Administrator via phone/ Appeal Rights Provided / A Copy of the Report Issued.