complaint·June 3, 2025

During interviews with the residents, three (3) out of four (4) did not corroborate the allegation. One resident stated that they have never been locked out of the facility by the staff. Another resident stated also stated that they have never been locked out of the facility in the past. During interviews with the staff, none of them corroborated the allegation. One of the staff members stated that they were coordinating with the hospital social worker to determine if R1 required a higher level of care before admitting them back to the facility, however they did not lock them out of the facility. Another staff member also explained that they did not lock R1 out of the facility and had allowed her to return following their hospitalization. During the visit LPA confirmed R1 had returned to the facility and was present during the visit. In regards to the allegation that " Staff are not dispensing medication as prescribed," it is alleged that the R1 was not obtaining their medication as prescribed. During interviews with the residents, none of the residents corroborated the allegation. One of the residents stated that they are obtaining their medications, however they need to make an appointment with their physician in order to obtain a prescription for one of their medications. Another resident interviewed stated that they have had no issues obtaining their medications. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that R1 was recently hospitalized and was provided with new orders that superseded R1's existing orders because they interacted with each other, but they are dispensing R1's medication as prescribed. Another staff member also explained that they are administering the hospital medication orders to R1 and that R1 has an upcoming scheduled appointment with their physician to update their orders. The incident reports involving R1 confirm their recent hospitalization beginning on 5/23/2025. In regards to the allegation that "Staff are not providing adequate transportation services to clients," it is alleged that R1 is not being assisted to their medical appointments by staff. During interviews with the residents, three (3) out of four (4) did not corroborate the allegation. One of the residents interviewed stated that their family take them to their medical appointments and have had no issues with obtaining transportation. Another resident interviewed stated that they have not had problems from getting assistance from facility staff in taking them to medical appointments. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that R1 had declined transportation services which is outlined as an optional service in their admissions agreement. During record review of R1's admissions agreements, it was revealed that they declined the transportation optional service in their admissions agreement. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 this report was provided. During interviews with the residents, one (1) out of four (4) residents corroborated the allegation. One of the residents reported that they did have stains on their bed that hadn't been cleaned. The other residents of the facility stated that their linens had been cleaned in a timely manner. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that they do clean the bedsheets of residents and that it is performed once per week. Another staff interviewed also indicated that the bedsheets of residents are cleaned once per week or immediately whenever they become soiled. LPA inspected the beds of the residents of the home and found that R1's bedsheets do have red stains. Photographs were taken of the stains on the bed as well. Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED . California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D. Exit interview was held and a copy of the report along with the appeal rights were provided.