complaint·March 21, 2023

Allegation: Staff are retaliating against resident for complaining. It is alleged that facility staff are retaliating/harassing resident (R1) because on 3/17/2023 the resident was provided a 2nd copy of the House Rules after filing a previous complaint with Community Care Licensing. According to staff interviews conducted, the findings indicate that the resident has history of smoking cigarettes in the room and during a prior CCL visit conducted by another LPA it was noted that R1's room had a strong marijuana odor. All staff denied the allegation, but confirmed the No Smoking policy has been addressed with the resident in a non-retaliatory manner. A total of 10 residents were interviewed. Two (2) out of the 10 residents stated that administration staff have retaliated against them in instances in which they complain about other residents, and/or when they complain about staffing not doing their job after daytime hours. The facility House Rules state "In order to promote a healthy environment in the facility, we have established a "No Smoking" policy in ALL INDOOR common areas and rooms. Smoking is however, permitted in the designated smoking areas only. The "No Smoking" policy includes all elevators, hallways, stairwells, public restrooms, courtyards, and patios." Therefore, there is in insufficient evidence to corroborate the allegation. Allegation: Staff do not ensure residents are prohibited from smoking when oxygen is in use. It is alleged that there is a resident that lights up cigarettes in its room and there is oxygen tanks in the room. The findings revealed that resident (R2) has been observed by staff and residents smoking inside the room, in which there in oxygen in use. According to Assistant Administrator, R2 has been observed lighting a cigarette in the room and walking out of the room to go smoke in the outdoor designated smoking area. Three (3) out 10 residents stated they have observed R2 smoke in the room where oxygen is in use. The residents confirmed that R2 has been addressed regarding the No Smoking policy and Oxygen Use. Staff stated that when and if they observe any resident smoking indoors they are immediately reminded that smoking is prohibited indoors. In addition, staff are trained to watch out for indoor smoking by residents. Per staff interviews, on 2/2/2023 resident (R2) was issued a Behavior Contract that discussed House Rules, No Smoking policy, and smoking area escort assistance. Staff are closely watching the resident to ensure no indoor smoking is being done. See next page. Allegation: Staff does not ensure resident is accorded privacy during phone calls. It is alleged that on 3/17/2023, the Assistant Administrator attempted to eavesdrop on R1's phone conversation, and was overheard asking hospice staff to tell him if the resident was making a call to Community Care Licensing. A total of five (5) staff were interviewed. All denied the allegation by stating that residents are always accorded privacy while they are using their phones in their rooms, lobby areas, and when they use the facility wireless telephone. Three (3) out of 10 residents stated that Administrator and staff seem to target specific residents. For instance, a resident stated that staff do not knock at the door or announce themselves and enter while they are talking on the phone. Another resident stated that Administrator seems to eavesdrop only on certain people. However, the majority of the residents stated that they are afforded privacy by facility staff, and that Administrator does not eavesdrop, but rather stops by the resident rooms to see how they are doing. LPA observed a wireless facility phone in the lobby area, and another phone located in the private marketing office that can be used by residents. There is insufficient evidence to support the allegation. Although the allegation(s) 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. No Deficiencies cited under California Code of Regulations Title 22 Exit interview was conducted with Assistant Administrator Alexander Solorio. A copy of the report was issued.