complaint·May 5, 2025

It was alleged that large ceiling leaks developed resulting in wet floors and other unsafe conditions and the facility did not properly address the leaks or communicate the situation to residents’ responsible parties. LPA interviewed AD and facility staff who stated that in February 2025 there was a leak that affected the first-floor hallway and nearby rooms, the situation was communicated to affected residents, measures were taken to mitigate the effects of the leak and ensure the health and safety of residents, and the leak was repaired as quickly as possible. LPA inspected the facility, including 14 resident rooms and all common areas, and observed that the damage from the leak has been repaired. LPA interviewed 11 residents and did not obtain information corroborating the allegation. However, LPA observed large stains under the bathroom sink, as well as water damage on the wall behind the toilet, in one resident room which appeared old and had not been repaired. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that staff did not keep the facility free of mold: it was alleged that large ceiling leaks developed in the first-floor hallway near the dining room and in the second-floor memory care resulting in wet ceilings and mold and the facility did not properly address the mold. LPA interviewed AD and facility staff who stated that in February 2025 there was a leak that affected the first-floor hallway and nearby rooms, the leak was addressed as quickly as possible, the leak did not result in mold, facility staff tested affected rooms for mold and the results were negative, and the leak and ceiling were repaired and the carpets were changed to ensure no mold developed. LPA inspected the facility, including 14 resident rooms and all common areas, and did not observe evidence of mold. LPA interviewed 11 residents and did not obtain information corroborating the allegation. However, LPA observed large stains under the bathroom sink in one resident room as well as water damage on the wall behind the toilet which could possibly be mold. Per facility staff, this water damage has not yet been tested but is going to be repaired soon. The information obtained is conflicting. Regarding the allegation that staff did not take precautions to prevent the spread of illness: it was alleged that there was a large infectious disease outbreak, and the facility did not properly address the outbreak or report the situation to residents’ responsible parties. LPA reviewed facility incident reports dated December 19, 2024, and December 23, 2024, which indicate 11 residents developed gastrointestinal symptoms, the outbreak was reported to local public health, and the facility was following the infection control guidance provided by local public health. LPA reviewed the facility’s infection control plan and noted it to be complete and current. LPA interviewed AD and facility staff who stated the gastrointestinal outbreak affected a total of 15 residents, facility staff reported the outbreak to local public health and followed the infection control guidance they received, facility staff notified the families of all residents, the outbreak ended on January 1, 2025, and no residents were hospitalized because of the outbreak. LPA reviewed the facility’s communications with local public health which show the facility notified local public health of the outbreak and received guidance on infection control protocols. LPA inspected the facility and observed sufficient supplies of masks, gloves, sanitizer, and gowns and also observed staff wearing personal protective equipment (PPE) while providing care to residents. Out of the 11 residents interviewed, some recalled seeing staff take infection control precautions during this outbreak, while many were unable to say. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. It was alleged that, in late December 2024, there was a large infectious disease outbreak which was not handled properly because AD and facility staff are not properly trained. LPA interviewed AD and facility staff who stated the gastrointestinal outbreak affected a total of 15 residents, facility staff reported the outbreak to local public health and followed the infection control guidance they received, facility staff notified the families of all residents, the outbreak ended on January 1, 2025, and no residents were hospitalized because of the outbreak. LPA reviewed AD’s administrator certificate which is current and indicates that AD’s administrator training is current. LPA reviewed the training records for five staff and confirmed they have completed the required caregiver annual training. Per AD and facility staff, staff are trained on infection control as part of their training. LPA reviewed staff training records dated December 18, 2024, which show staff were trained on gastrointestinal infections as part of the facility’s response to this outbreak. LPA did not obtain any information corroborating this allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.