complaint·July 25, 2023

The investigation revealed the following; Allegation: Staff did not treat residents with dignity or respect. The details of this allegation states that on 9/7/22, at approximately 12:40pm, S1 started shouting at R1 at the top of her voice while sitting inside the office, which was approximately 30 feet away from where R1 was standing. S1 shouted in Spanish and the tone she used was humiliating and intimidating towards R1. Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegation. The alleged incident happened on 9/7/22, at approximately 12:40pm. R1 was standing in the hallway, near the office and was overheard yelling “bano” repeatedly, indicating he wanted a shower. S1 was on her break sitting inside the office, approximately 30 feet away from R1 and instead of getting up to address R1 that she was on break, S1 began yelling at R1 in Spanish, stating that “I’m on my break right now, I will shower you”. There were multiple witnesses who observed the incident and stated that S1 was observed yelling at R1 in a humiliating and intimidating manner and could have addressed the situation differently by getting up and explaining to R1 that she was on her break and would assist him with his shower upon returning from break. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegation to be true. Allegation: Insufficient staff meeting the qualifications and competency to meet residents' care needs. The details of this allegation states that on 9/7/22, at approximately 12:40pm, a witness observed that there were two caregivers on shift, one of whom was S1 and S1 was on break at the time. When the witness inquired with S3 if that meant that there is currently only one caregiver on the floor, S3 stated that "there are two kitchen staff who help too”. S3 was asked if that meant that kitchen staff were assisting with resident care needs, S3 replied “yes”. Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegation. Statements obtained from staff and residents stated that S4, who works in the kitchen, will often times assist residents with care. After reviewing the file of S4, LPA observed that S4 does not have the required training to provide resident care, such as assisting with showers, changing and providing incontinence care. Also, S4’s CPR/First Aid Certificate had expired on April 30, 2022. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegation to be true. (Please see LIC 9099C for additional information) Based on LPA’s observations and interviews which were conducted and record reviews, 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. The investigation revealed the following; Allegation: Staff did not respond to residents call for assistance in a timely manner. The details of this allegation states that R1 called out from the hallway "bano" repeatedly, indicating they required assistance with bathing. Despite this, no staff members came to assist him. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. The alleged incident happened on 9/7/22, at approximately 12:40pm. R1 was standing in the hallway, near the office and was overheard yelling “bano” repeatedly, indicating he wanted a shower. According to staff, R1 receives showers from the hospice nurse twice a week. R1 was not scheduled for a shower on 9/7/22 but staff told R1 that they would assist him with his shower once they were done giving showers to the residents on schedule for that day. At the time of the alleged incident, there were two caregivers working. One of the caregivers was on break. The Med Tech was assisting with passing out medications and the Activities Director and the Assistant Administrator were also on duty assisting other residents with care. Statements obtained from residents denied staff not responding to residents call for assistance in a timely manner. Based on the information gathered, there was insufficient evidence found regarding the above-mentioned allegation. Allegation: Facility is unsanitary. The details of this allegation states that on 9/7/22, between 12:40pm and 1:10pm, discarded plates of food were observed in the hallways and on the floor, as well as discarded soiled clothes. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. Statements obtained from staff stated that the only time empty plates of food can be found on the floors are after lunch as some of the residents have a habit of placing their empty plates on the floors, in front of their rooms so that staff can pick them up. Some residents also leave their dirty/soiled clothes on the floors, in front of their rooms so that staff can pick them up for laundry. Staff remind residents who tend to leave their plates on the floors to leave the plates in their rooms for staff to pick up but residents continue to leave them on the floors. Staff also remind residents not to leave dirty/soiled clothes on the floors and to call staff for assistance in picking up their dirty clothes for laundry. Residents interviewed stated that staff are quick to pick up empty plates from hallway floors after lunch and denied seeing dirty/soiled clothes in the hallways. During the visit conducted on 10/20/22, LPA toured the facility (physical plant / inside only) in the AM and also in the PM and did not observe discarded plates of food or soiled clothes on the hallway floors. Based on the information gathered, there was insufficient evidence found regarding the above-mentioned allegation. 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 to the Assistant Administrator.