complaint·August 25, 2022

Based on interviews conducted the statements obtained were consistent and corroborated with the allegation. Residents and staff interviewed confirmed that the fire doors that exit to the back patio (where residents take breaks) are too heavy for residents in wheelchairs to open. Often times, residents will wait on staff to come and open the doors for them because they are unable to keep the door open and wheel themselves out at the same time. During today's visit, LPA tried opening the fire doors that exit to the back patio and observed the weight of the doors and based on LPA's observation, it would be very difficult for anyone in a wheel chair to hold the door open and wheel themselves out at the same time. Based on interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true. Allegation: Residents soiled linen is not changed timely. Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the allegation. Residents confirmed that linens and bed sheets are not changed regularly and often times residents have to request for their linens to be washed/changed because staff will not change them. There have been times where residents linens and bed sheets have not been changed for more than two weeks. During today's visit, LPA toured a random selection of resident rooms and observed the linens in rooms 33, 34B, 38B and 36B were soiled/dirty. Blood stains were observed on the linens in rooms 34B and 38B and on the pillow case in room 33. The pillow case in room 36B was torn and covered in stains. Based on majority of the interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true. Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights. Based on interviews conducted the statements obtained were inconsistent and did not corroborate with this allegation. During the interview of Resident 1 (R1), R1 was not able to identify the date & time of the incident in order for LPA to review the surveillance camera at the facility and see the details surrounding the incident. According to the Assistant Administrator, he was informed of the incident from R1 and offered to call R1's insurance company to have it replaced but R1 refused as she handles her own concerns. The Assistant Administrator offered to give R1 a loaner wheelchair but R1 refused. The Assistant Administrator was unsure if the incident occurred at the facility as R1 did not provide a date and time of the incident. According to R1, R1 was hospitalized about a month ago and the hospital replaced her old wheelchair by giving her a new one. During today's visit, LPA observed R1 using a new wheelchair. Based on the information gathered, there is insufficient evidence to support this allegation to be true. Allegation: Trash in resident rooms are not being emptied often. The details of this allegation states that Residents soiled diapers are not emptied often from the trash container inside of resident’s room. Based on interviews conducted the statements obtained were inconsistent and did not corroborate with this allegation. Residents and Staff interviewed confirmed that trash is emptied in resident rooms regularly, which is once a day or as needed. Soiled diapers are not disposed in trash bins located in resident rooms and are disposed in the big trash bins located in the hallways, which are emptied during each shift. During today's visit, LPA toured a random selection of resident rooms and did not observe trash and or diapers in the bins located in resident rooms. LPA did not observe an overflow of trash anywhere. Based on interviews conducted and LPA's observation, there is insufficient evidence to support this allegation to be true 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 allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided.