complaint·February 27, 2024

It is alleged that the staff is not providing adequate care and supervision to the individuals in care. During the visit conducted on February 14, 2024, from 3:15pm to 5:30pm, LPA Cho observed six residents and two caregivers on duty. The Administrator was also on premises upon LPA’s arrival. Per LPA’s observations, caregivers were actively assisting the residents during the visit today and on February 14, 2024. Per review of the appraisals, it was documented that two out of the six residents need special observation/night supervision. Based on the interviews conducted, one out of the two residents indicated that care and supervision is not provided after 7:00pm. Two out of the three staff interviewed indicated that care is only provided upon request when their shift ends at 7:00pm. Both staff also indicated breaks are taken at staggered times to ensure residents’ needs are met throughout the day, however routine checks are not conducted after 7:00pm. It is alleged that the residents are left in their soiled clothing. Based on the observations made on February 14th during the diaper inspection requested by LPA, LPA along with the staff observed that the diaper for one out of six residents was visibly wet at 3:34pm evidenced by the yellow and heavy appearance. The stool was also observed to be impacted in the rectum. During today’s inspection with the staff approximately 9:40am, all diapers were dry. Per interviews conducted on February 14, 2024, one out of the two residents indicated that requests for diaper changes would go unanswered after 7:00pm until the next morning. Three out of the three staff interviewed indicated that routine checks are conducted every two hour interval during the day while checks during the nocturnal hours are not conducted unless requested. Based on LPA’s investigation, although residents are routinely checked every two hours during the day and upon request during the day and after 7:00pm, residents who are non-verbal, confused, and disoriented are unable to verbalize their needs. Documentation also noted that the two out of the six residents need special observation/night supervision to ensure that their needs are being met at all times. Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Staff is not providing adequate care and supervision to individuals in care and Residents are left in their soiled clothing are deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Carol Wilson, and a copy of this report including the LIC9099C, LIC9099D, and the appeal rights were provided at the end of the visit.