complaint·September 6, 2024

The investigation revealed the following: Allegation: Staff are not preventing the spread of COVID-19. LPA toured facility alongside of Stephanie Funderburg (Executive Director) and Ann-Marie Boersma (Wellness Director) and observed hand sanitizing stations throughout facility, LPA tested the sanitizing stations in common areas and they were operable. There is one resident that was recently on isolation (last day was yesterday), signage of corona virus was at the door and there was a sanitizing station with masks, gloves, gowns, and hand sanitizer outside of their room. LPA observed a storage room in memory care that had sufficient PPE supplies, such as masks, gloves, gowns and hand sanitizer. LPA obtained copies of letters informing Residents and Family/Responsible parties that were sent out, informing them that there have been Covid Positive cases and encouraging all to wear masks, as well as staff. Throughout the tour LPA observed multiple staff and residents without masks, however, given the recent Rescission of Health Officer Order for the City of Pasadena as of March 5,2024, the order requiring masks by personnel, patients, clients and visitors in health care settings issued March 29.2023 by the health officer of the City of Pasadena is rescinded in its entirety, this information was provided to LPA by the Department of Public Health. LPA interviewed 12 Residents and 10 out of 12 Residents denied the above allegation. 10 residents stated that have observed staff wearing masks and have masks and hand sanitizer readily available for them, they also stated that they were informed of the outbreak and encouraged to wear masks. LPA interviewed 5 staff and 5 out of staff denied the above allegation and stated that they have been encouraging masks, sanitizing and have notified residents of the outbreak. LPA special incident reports that were submitted to licensing, and noticed that the Covid outbreak was not reported per the 24 hour reporting requirement. This will be detailed in a separate case management report. Based on statements and interviews conducted with staff and residents, review of documents/records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.