Inspector’s narrative
What the inspector wrote
The investigation revealed the following: in regards to the allegation "Staff does not ensure facility is in good repair.” It is alleged that there are mass problems with plumbing with many bathrooms that don’t work and have sufficient heat for water. The Assistant Administrator, three (3) out of four (4) staff denied the allegation. One (1) out of four (4) staff did not know so did not provide an answer to the allegation. Six (6) out of eight (8) residents denied the allegation. LPA checked 9 residents’ bathrooms hot water measured between 105 to 120 Degrees F which is within Title 22 Regulations. However, water temperature in bathroom #5 was measured at 142.1 Degrees F. This deficiency will be addressed on a separate case management report. LPA observed that all 9 bathrooms observed have working toilets. However, the bathroom in Rm#11 had a showerhead that was not working properly with water pressure was insufficient for a resident to take a shower. The bathroom in Rm#29 also was clean and well-kept but had a very foul odor from an unknown source. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was sufficient supportive evidence to concur with the reported allegation.
Allegation: “Staff does not provide a safe environment for residents.” It is alleged that there were workers peeling the previous stuff on the wall creating a mess and endangering the residents to fall. All staff interviewed denied the allegation. Seven (7) out of eight (8) residents denied the allegation. One (1) out of eight (8) residents stated while moving belongings from one room to another, the resident slipped on a pad that was placed by a staff due to a leak which caused the resident to sustain an injury. LPA also observed during the initial visit dated on 2/7/2025, construction workers working on the 2
nd
floor and noticed tools such as hammers, mallets, drills, vacuum cleaners, wires, and vinyl flooring tiles in the hallway which are potential trip and fall hazards. LPA confirmed that there are residents living in these areas and residents potentially have access to these items. LPA observed workers working inside of the rooms and there is no staff ensuring that the residents are not grabbing or accessing these items. LPA took pictures of all of these tools during the visit dated 2/7/2025. In addition, there are no posters, warning signs or items giving a residents a heads up of the issues of these items in the hallway. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was sufficient supportive evidence to concur with the reported allegation.
Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D.
Exit interview held with the Administrator, Claudia Sanchez, and a copy of this report and appeal rights were provided.
During today's visit, LPA obtained the following documents: Staff and Client roster.
Allegation: “Staff do not provide adequate food service to residents.” It is alleged that there is a lack of food and nourishment in the facility, and if residents request more food, they don't get it. During today’s visit, LPA interviewed the Administrator and all staff denied the allegation. All staff interviewed indicated that all residents at the facility receive three meals and three snacks per day. All staff interviewed also indicated that facility provides a sufficient amount of food to all of the residents in care. LPA interviewed eight (8) out of eight (8) residents all claim they get enough food from the facility staff and are provided food, snack, or drink when they request it. LPA toured the kitchen and dining area. LPA observed that there is an sufficient amount of 2-day perishable and 7-day non-perishable food at the facility. LPA also received and reviewed the weekly meal schedule which indicate well balanced meals. LPA observed residents eating their meal at the dining hall during lunch time from 12:15pm to 12:45pm. LPA observed eating the following items for lunch during the visit: Grilled chicken, white rice, vegetables, and sweet tea or water. Residents were in a pleasant mood while continuing to eat lunch. Assistant Administrator and all staff interviewed also mentioned that residents are provided alternative meal options, snacks, and sandwiches if residents asks for it. LPA observed no concerns regarding residents not getting enough food from the facility. Therefore, there was insufficient evidence to corroborate with the allegations.
Allegation: “Staff do not provide a comfortable temperature for residents.” It is alleged that there is no heat or air conditioner on the whole top floor. All staff interviewed denied the allegation. Six (6) out of eight (8) residents denied the allegation. Two (2) out of eight (8) residents stated that the bedroom was either too hot or too cold. According to the resident interview, one of the residents temporarily moved to the first floor. The other resident has a portable heater which helps manage to keep the bedroom at a warm temperature. During the visit, LPA noticed the facility temperature on the 1
st
and 2
nd
floor to be at an appropriate temperature and not at a temperature of concern. Based on staff interview, the Assistant Administrator stated that there have been no current issues with the air conditioner and heater. Assistant Administrator stated that if there were any complaints, the facility maintenance department would be informed and the problem would be resolved. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.
Allegation: “Staff does not treat residents with dignity and respect.” It is alleged that the staff harassed a resident multiple times. Interviews conducted with the Assistant Administrator and four (4) out of four (4) staff denied the allegations. Eight (8) out of Eight (8) residents interviewed denied the allegations and stated that they are not harassed by the staff and are satisfied with the services they receive at the facility and stated that staff treat them with dignity and respect. No paperwork observed in the files that showed the staff have been reprimanded for mistreating, harassing, or disrespecting staff. LPA also reviewed staff training on Proper Hygiene Practices, Dignity and Privacy date of training 1/16/2025 and Dementia Residents and Resident Rights date of training 4/24/2024. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.
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 is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview held with the Administrator, Claudia Sanchez and a copy of this report was provided.
