complaint·March 14, 2023

Interviews with staff show that residents are offered seconds after everyone has received a meal and residents can request different meals ahead of time also. Interviews do not show that the facility runs out of meals or refuses to provide other options to residents. Based on interviews, observations and files reviewed; 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, therefore the allegation is unsubstantiated. In regards to the allegation "Facility staff does not respond to residents’ call buttons in a timely manner. " it was alleged that staff will take long to address residents call button. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews with residents detail staff responses from call buttons to be anywhere between 2-10 minutes depending on how busy staff can be. During the visit and unknown to staff, LPA entered room #207 and pulled the emergency cord. Staff arrived within 2 minutes to check in on residents of that room because of the pull cord. Interviews with staff state that no emergency signals are ignored. Based on interviews and observations; 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, therefore the allegation is unsubstantiated. In regards to the allegation "Facility staff retaliates against residents for making complaints." it was alleged that facility staff neglect the care of residents because of residents that make complaints. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews do not show that staff retaliate against residents for making complaints. Interviews with staff state that they will always listen to resident complaints and address any issue. LPA did not observe residents being neglected at the time of the visit. Based on interviews and observations; 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, therefore the allegation is unsubstantiated. In regards to the allegation "Facility staff are not ensuring safety of residents' personal possessions." it was alleged that there has been theft of clothes, radios, and small amounts of cash at the facility. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews do not show that there have been witnesses to acts of stealing in the facility. LPA was not provided with a name of who was stealing items in the facility..... Continued on LIC 9099-C (1) of (6) residents interviewed stated clothes has gone missing from their possession but was not sure who took it. Staff interviews deny stealing any personal possessions from residents in care. Based on interviews and observations; 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, therefore the allegation is unsubstantiated. In regards to the allegation "Facility staff member did not respect residents' privacy by knocking on their door before entering their room." it was alleged that S2 enters residents rooms without knocking or permission. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews show that staff will go from room to room for multiple reason throughout the day. There are clients who need assistance with medication, assistance with grooming, and assistance in room cleaning. Staff will also conduct room checks when residents are not responsive to door knocks. Interview with S2 denies that they have ever entered a residents room without knocking and identifying first. LPA was not provided with proof of S2 entering resident rooms unannounced. During the visit, LPA observed S2 knock on doors and announce themselves before entering. Based on interviews and observations; 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, therefore the allegation is unsubstantiated. In regards to the allegation "Facility staff did not seek a resident timely medical attention." it was alleged that facility staff did not call 911 in a timely manner for R2. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. File review shows that R2 had a fall in the dinning room on 3/1/23 and also receives assistance from a hospice agency. Incident report collected states that the resident received first aid and their hospice agency was contacted and also was taken to the hospital. Interview with R2 corroborates the information on the incident report. Interviews show that S3 immediately assisted and assessed R2 then contacted responsible parties. Hospice agency determined it would be best for R2 to go to the hospital and so they were taken. During interview, R2 stated they agreed to wait for the hospice agencies decision about going to the hospital. Based on interviews, observations, and files reviewed; 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, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report was provided. LPA reviewed the facilities employee handbook which states staff are too not borrow money from residents. No other staff or residents were aware of the incident. LPA observed text communication between R1 and S1 that shows details of S1 borrowing money and acknowledging that they owe R1. This shows that during their employment at the facility, S1 did not abide by the facilities plan of operation. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided.