complaint·June 21, 2024

CONTINUED...During the course of the investigation, 4 of 4 interviewees indicated there were 2 staff working in Assisted living area and two staff working in the memory care unit during incident of R1s wandering behavior. Three of four interviewees indicated the need for additional staffing during the night shift. Regarding the allegation that “Staff did not adequately notify resident’s authorized representative of a change in resident's placement,” the investigation revealed the following: The Facility attempted to communicate with who the facility staff believed to be R1’s responsible party; however the facility contacted a Family member identified on the LIC 601-Identification and Emergency Form under Person(s) responsible for financial affairs, payment for care, legal guardian if any, but not the authorized representative. Regarding the allegation that “Staff inappropriately placed resident in a locked unit,” the investigation revealed the following: The facility did not provide the resident and responsible party with a 30 day notice, and did not communicate with Authorized representative prior to placing the resident in delayed egress memory care unit. Although, the facility was attempting to ensure R1s Health and Safety by placing R1 in delayed egress memory care unit, the facility attempted to substitute R1’s supervision needed to meet R1s need and provide necessary supervision. Therefore, based on evidence through records reviewed and interviews conducted the allegations “Staff did not provide adequate supervision, resulting in a resident wandering away from the facility,” “Staff did not adequately notify resident’s authorized representative of a change in resident's placement,” and “Staff inappropriately placed resident in a locked unit” are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that a violation has occurred. (SEE LIC 9099-D) The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with (AD) Jeri Miles and (HWD) Brisseth Rivera, and a copy of this report, Appeal rights, LIC 9099-D page, and LIC 811- Confidential names were provided at exit. CONTINUED... responding paramedics and SCAN provider and by the SENIOR DOC provider on 2/10/2024 and reassessed by the SCAN provider on 2/11/2024 at 12:57am and 3/26/2024 at 1:57pm. Interview conducted with 1 of 1 witness reported that the assessment with SENIOR DOC on 2/10/2024 may have been inauthentic, multiple attempts were conducted to interview provider with SENIOR DOC, however, LPA Quiroz was unable to speak to SENIOR DOC provider. Interview with 1 of 1 witness reported that the assessment with SCAN on 2/11/2024 may have been inauthentic as the witness reported the SCAN provider was not on duty at the time of the reported assessment. I nterview with 1 of 1 witness reported that the assessment dated 3/26/2024 may have been inauthentic as R1 was not present at the facility on the date and time of the reported assessment. Therefore based on the preponderance of evidence gathered through interviews, documentation review and observations conducted by LPA Quiroz, the allegation that the " Staff did not conduct a timely reappraisal following a change in resident’s condition," was found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Jeri Miles and a copy of this report, LIC 811-Confidential names were provided at exit. ***THIS IS AN AMENDED REPORT***