complaint·November 13, 2023

During today’s visit LPA interviewed R1’s family member (FM) and delivered findings. The investigation reveals the following: Regarding “Facility left resident unsupervised in facility vehicle”. It is alleged that the facility left R1 on the facility shuttle from 3 pm- 8:45 pm. The Executive Director confirmed there was an incident where S1 forgot R1 in the vehicle. Shas since been dismissed from their position. 3 out of 3 staff confirmed that S1 left R1 in the vehicle unintentionally, and R1 was sent to the hospital for further evaluation. 7 out of 10 residents stated they use the facility shuttle and have had no issues. 3 out of 10 residents stated they do not use the facility shuttle. Upon file review, LPA observed R1 has a secondary diagnosis of Dementia. LPA also received an incident report from the facility confirming the incident. The investigation reveals the following: Regarding “Facility did not provide care to resident. It is alleged that the facility did not provide care for the resident during the hours the resident was left unattended in the facility shuttle. The Executive Director confirmed there was an incident where S1 forgot R1 in the vehicle. 3 out of 3 staff confirmed that S1 left R1 in the vehicle unintentionally. 8 out of 10 residents confirmed the facility provides care. 2 out of 10 residents stated the facility do not provide enough care. LPA Baptiste received an incident report from the facility confirming staff tried to locate R1 but did not find R1 until 8:45 pm. During the time the resident was in the shuttle, no care was provided. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D and civil penalties assessed. Exit Interview Conducted with Executive Director Kevin Taliaferro / Appeal Rights Provided / Civil Penalties Assessed/ A Copy of the Reports Issued.