Complaint·November 19, 2024

door to access the bedroom 6B for purposes of either sleeping, using restroom and or gathering personal staff belongings located in room. R2 and R3 stated they are not aware that R1’s bedroom is being used as a passageway to another bedroom. S1 and S2 confirmed that S4 sleeps in bedroom 6B. Based on the department’s observations, it was confirmed that only way through bedroom 6B is passing through Resident 1’s room 6A. The department also observed bedroom 6B has sheets and blankets on bunk bed as well as personal hygiene items located on dresser and clothing inside closet. Regarding allegation, Licensee does not provide a resident privacy at the facility. Interviews were conducted with three (R1-R3) of five residents and three (S1-S3) staff. Interviews with three residents (R1-R3) confirmed that staff enter resident rooms with or without notice. R1 stated S1, S2 and S4 enter R1’s bedroom 6A entrance to access bedroom 6B for the purpose of sleeping, using the bathroom or accessing their personal belongings not allowing resident privacy. Interviews with two staff (S1 & S2) revealed that they sometimes use the bathroom next to bedroom 6B and the only access is through R1’s bedroom 6A. Based on the department’s observations, it was confirmed that only way through bedroom 6B is passing through Resident 1’s room 6A. Based on observations, interviews and record review, the preponderance of evidence has been met, therefore the allegations, “Resident’s bedroom is used as a passageway to another room at facility and Licensee does not provide a resident privacy at the facility”, are deemed SUBSTANTIATED. The following is being cited on attached LIC 9099D. An exit interview was conducted with Caregiver Clavecilas and copies of this report along with Appeals Rights was provided. Regarding allegation: Staff do not ensure that food served to residents is free from contamination. During investigation, interviews were conducted with three (R1-R3) of five residents and three (S1-S3) staff. R1 stated they observed meat left out on stove all night and has observed staff re-use same pan with oil to cook other foods throughout day. Two residents (R2 & R3) stated they have no issues with food preparation at facility. Based on the department’s observations, facility staff wash their hands before prepping meals, staff use separate pans for cooking and staff wear gloves while cooking. Based on the information provided for investigation, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations, “Licensee is not addressing pests at the facility and Staff do not ensure that food served to residents is free from contamination” did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Caregiver Clavecilas and copy of this report along was provided.