complaint·January 4, 2024

Based on Allegation: Staff handle residents roughly during diaper changes. Investigation revealed: Assistant Administrator and S1-S4 informed LPA that they haven't witnessed or observed any staff handling residents roughly when having their adult brief's changed. (5) out of (5) staff informed LPA during interviews that they change every incontinent residents in a proper way that is not rough and deny the above allegation. (5) out of (7) residents informed LPA staff haven't treated them rough when getting their adult brief's changed. Based on Allegation: Residents are afraid of retaliation from staff if they disclose concerns to the Ombudsman (LTCO) and Licensing (CCLD). Interviews with (7) out (7) residents interviewed on 7/6/23 LPA was informed that resident deny the above allegation and they are not afraid of staff retaliating residents if disclosing information. R1 informed LPA they are not afraid of retaliation by staff but concern they staff ask what was disclosed to CCLD and LTCO. LPA observed CCLD and LTCO posters with information to contact agencies per rights of the residents/ staff and visitors located in the hallway. 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. Exit interview held and a copy of the report was provided Based on allegation: Night staff do not respond to assist residents with care. (4) out of (7) residents interviews with LPA on 7/6/23 revealed caregivers did not attend to residents during the night. Although residents were not able to inform LPA with a time frame on wait time residents informed LPA they would wait for a long time or the night staff were not doing rounds to check on them. (3) out of (5) staff during interviews informed LPA being aware of residents informing staff that night shift staff were not efficiently responding attending to residents at night. S3 and S4 informed LPA R1 calls staff frequently around 3-5 minutes asking for assistance and although R1 may need to wait at times because staff are doing their duties and caregiving are attending to all residents needs, R1 does receive assistance.LPA reviewed resident(s) in-service log sheet for R1, R2, R4 R5 logs showed no indication of nocturnal shift logging in-service for residents listed between months of June-July 2023. Assisted Administrator and S1 stated caregivers duties are to check on residents every 2 hours during rounds and as needed. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations per Title 22, 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.