complaint·January 15, 2025

Regarding the allegation that staff do not treat residents with dignity or respect: it was alleged that residents go to dinner without shoes and without showering for days, facility staff argue with and intimidate residents who bring up concerns at resident council meetings, and facility staff stand around gossiping about residents and disclosing their confidential information. LPA observed one resident walking around the facility barefoot on January 10, 2025, and the same resident walking around the facility wearing only socks on January 13, 2025. Per COO, the facility has not received complaints about residents going without shoes and has not addressed this issue with any residents. LPA did not observe any residents with offensive odors throughout the facility and out of 13 residents interviewed, none had offensive odors and none reported concerns regarding showers or the hygiene of other residents when asked if they were experiencing any problems at the facility. Per COO, residents receive showers twice a week, some residents refuse but facility staff can usually work with them and convince them to shower. LPA reviewed the facility’s shower log for December 2024 which shows only four shower refusals for the month. LPA interviewed 13 residents, none of whom corroborated that staff argue with or intimidate residents at the facility. However, two residents reported witnessing staff making fun of a resident who has issues with speech by mimicking them and one resident reported that staff shared personal information about how this resident developed their issues with speech. The information obtained corroborated the allegation. Regarding the allegation that staff allow residents to smoke in areas not designated for smoking: it was alleged that residents are allowed to smoke in their rooms leaving the building smelling like smoke. LPA inspected the facility and noted a strong smell of cigarette smoke coming out of one room and Resident #1 (R1) smoking in the front courtyard of the facility where there are multiple “no smoking” signs with dozens of used cigarettes and a lighter on the ground near R1. LPA reviewed the facility’s house rules which state that smoking is only allowed in the designated smoking area and smoking is prohibited inside the building and where there are “no smoking” signs. When interviewed, COO stated the only designated smoking areas are in the central courtyard and residents are not allowed to smoke in their rooms or anywhere else. COO could not provide information about the resident whose room smelled like smoke, but stated that R1 has been at the facility for about six months, facility staff tell R1 they can only smoke in the designated smoking areas but R1 does not listen, the facility is working with R1’s responsible party regarding this issue, and the facility has issued one written warning to R1 but has not issued an eviction notice. LPA interviewed 13 residents, five of whom corroborated that the facility is not doing enough to enforce the house rules and ensure the inside of the facility is smoke-free, including one resident who asked R1 to stop smoking in non-smoking areas and was yelled at by R1. The information obtained corroborated the allegation as the facility is not properly identifying and addressing rooms that smell like smoke and has not moved quickly enough to address R1’s constant violation of the house rules. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. 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 do not keep the facility clean or sanitary: it was alleged that common areas are cluttered with trash preventing residents from enjoying these areas of the facility, residents on the second floor have pets they cannot properly care for or clean up after leaving the facility malodorous, and staff hours were cut resulting in the facility floors not being mopped. LPA inspected the facility and did not observe any clutter, trash, or unclean floors. LPA interviewed COO, who denied the allegation and stated that the housekeeping staffing levels have actually increased. LPA reviewed the facility’s housekeeping schedule for September 2024 through January 2025, which shows that the number of housekeeping staff has increased slightly. LPA noted mild, but not unpleasant, pet odors in the room of R2. LPA reviewed a photograph of R2’s dog which shows that it urinated in a common area, however it is unclear how much time elapsed before R2 or facility staff cleaned up after the dog. Per COO, R2 is a good resident, their dog is friendly and other residents like this dog, the dog generally stays outside, and R2 cleans up after their dog and facility staff will clean up after the dog if R2 does not. LPA noted strong and unpleasant pet odors in the room of R3. Per COO, R3’s dog is a problem, R3 did not move in with the dog, the facility has tried multiple times to get R3 to get rid of the dog, and the facility is in the process of evicting R3 due to the dog and other issues. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is taking proper measures to address R3’s violation of the house rules. Out of 13 residents interviewed, 12 reported no concerns with cleanliness or pets at the facility. The information obtained did not corroborate the allegation and shows that the facility is addressing the issues raised by R3’s dog through the eviction process. Regarding the allegation that staff do not provide a safe environment for residents: it was alleged that some residents are involved in illegal activities, treat other residents and staff in a rude manner, and argue, do illegal drugs, and drink late into the night in common areas. LPA interviewed COO who denied the allegation. However, per COO, R3 violates the house rules and when the facility tried to enforce the house rules on R3, R3 became angry and shouted profanities in the past. One witness interviewed stated they saw R3 threaten staff. LPA reviewed a video showing R3 yelling at another resident. COO stated that the facility is in the process of evicting R3 due to their violation of the house rules. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is taking proper measures to address R3’s behavior. LPA interviewed 13 residents, 12 of whom stated they feel safe at the facility, well-treated by other residents, and have not seen any drugs at the facility, while one resident stated that other residents sometimes curse at them and they saw drug use once at the facility but the facility addressed it. LPA did not obtain information that R3 or any other resident is engaging in violence. COO stated that R3 has not engaged in violence and staff know to call police if R3 places other residents in danger pending their eviction. The information obtained did not corroborate the allegation and shows that the facility is addressing R3’s behavior through the eviction process. Regarding the allegation that staff do not keep the facility free of illegal drugs: it was alleged that some residents bring illegal drugs into the facility and do illegal drugs late into the night in common areas. LPA interviewed COO who stated that some residents claim other residents are doing drugs, facility staff have never found any proof of illegal drug use at the facility, and most of the allegations of illegal drug use have been made against R3 who the facility is in the process of evicting. LPA reviewed R3’s 30-day Eviction Notice dated September 19, 2024 and the facility’s Unlawful Detainer Complaint against R3 filed November 12, 2024, which show that the facility is in the process of evicting R3. LPA interviewed 13 residents,12 of whom stated they have not seen any drugs at the facility, while one resident stated they saw drug use once at the facility but the facility immediately put a stop to it. The information obtained did not corroborate the allegation. Regarding the allegation that staff do not safeguard resident's personal items: it was alleged that residents’ personal items are being stolen while in the facility. LPA interviewed COO who denied receiving any recent reports of lost property and stated they advise residents to lock their doors and take care of their property. Out of 13 residents interviewed, only one resident reported a theft at the facility. However, per the facility’s Admission Agreement, residents are responsible for securing their personal property and per COO, this resident did not entrust any property to the facility to safeguard so it was the resident’s responsibility to safeguard their property. In addition, COO stated that this alleged theft was not reported to the facility. It is also possible the resident misplaced their property and it was not stolen. Based on the information obtained, there is not a widespread issue of theft at the facility and the facility did not fail to safeguard any property that was entrusted to it. The information obtained did not corroborate the allegation. Regarding the allegation that facility staff violated resident’s personal rights: it was alleged that Staff #1 (S1) took an inappropriate photograph of Resident #4 (R4) and shared it with other residents. LPA interviewed 13 residents and did not obtain information corroborating this type of inappropriate behavior by staff. LPA interviewed the facility’s medication technician supervisor who confirmed that R4 has issues with taking off their clothes due to their mental condition, R4 has been observed naked outside their room and redirected back to their room, photographs of R4’s behaviors were taken and shared only with R4’s family to coordinate R4’s care, but could not provide information regarding whether any of these photographs were shared with other residents. LPA interviewed S1 who denied taking or sharing any photographs of R4 and stated that R4 is often observed naked outside their room, other residents commonly complaint about this behavior, whenever S1 sees R4 engaging in this behavior they redirect R4, and that at some point in the past photographs of R4’s behaviors were taken and shared only with R4’s family to coordinate R4’s care. LPA interviewed COO who stated R4’s behavior is the result of a recent decline, the facility has attempted to address R4’s behavior with R4’s family but R4’s family has not cooperated, and R4 is currently out of the facility and will be reassessed if they are to return to ensure their behaviors will be addressed by their care plan. LPA interviewed one additional staff who could not provide information regarding this allegation. During the course of the investigation, LPA did not obtain or see the alleged photograph. LPA attempted to interview R4, but R4 is not on the facility and R4’s family refused the interview. The information obtained did not corroborate that any inappropriate photographs of R4 were shared with anyone other than R4’s family and any alleged photographs could have been taken by other residents who saw R4. 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 the facility van is not working which prevents residents from being taken on outings because only one or two residents can be taken out at a time and a resident was showered and there was no hot water. LPA interviewed COO who stated the facility has a small bus and a sedan, the bus is used for residents in wheelchairs and it works. LPA inspected the facility bus and observed the bus and its lift used to allow residents in wheelchairs access worked properly. LPA interviewed 13 residents, none of whom reported issues with being transported to where they need to go. Per COO, the facility recently had to shut the water off for two hours to fix a pipe. LPA inspected the water and hot water for 13 residents and observed the water and hot water to be working properly. Out of 13 residents interviewed, five residents noticed this recent water outage and two of these residents had prior notice of the outage and knew that it was a planned outage to fix a pipe. Per COO, the facility provides notice of planned water outages by posting a notice by the activity wall and making an announcement over the intercom. LPA reviewed the facility’s water shut off notice for January 3, 2025, which warns residents that there will be no water from 6PM to 8PM for pipe maintenance. LPA reviewed the facility’s water maintenance logs which show the January 3, 2025, two-hour water outage was planned in order to allow maintenance staff to fix a pipe. The facility’s water maintenance logs also show multiple other repairs made to the water system, most of which did not require that the water be turned off. COO stated they will take additional measures in the future, including posting notices in additional locations and making multiple intercom announcements, to ensure all residents are aware of water outages. Based on the information obtained, the facility’s vehicle works properly and the facility is consistently maintaining its water system. This allegation is unfounded. 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.