complaint·July 7, 2022

work shifts, resident and staff rosters. The current staffing agencies utilized by the facility are Concierge Senior Services and Angel Connection. LPA Velazquez also conducted interviews with staff and residents who were able to corroborate the allegation. Some staff indicated they assisted wherever they were needed and worked as dining room servers which was not their primary role in the facility. Other staff indicated they worked excessive hours due to the lack of staff present such as a dishwasher. Some residents indicated they had to wait an extended period of time for their meals or desserts to be served due to the lack of servers present. On one occasion a staff member indicated they were the only server to cover the dinner shift. Direct care staff known as Care Partners have their work schedules divided between providing care and supervision directly to residents and then are also scheduled to work as servers which is not their primary role in the facility. LPA Velazquez observed this Care Partner work as a server with their name badge clearly identifying them as a Care Partner. This Care Partner also indicated that on that particular day there was no one to cover their shift as a Care Partner which left the direct care staff understaffed. The resident records reviewed included Physician's Reports, Care Plans, Care Pricing which documented the levels of care and corresponding fees, North Tustin Health and Service Evaluation Results, and Admissions Agreements. Based on the observations made, interviews which were conducted, and the records reviewed, the preponderance of evidence standard has been met, therefore the allegation of Staff are not providing adequate food service is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC 9099 D. An exit interview was conducted with Business Office Director Leo Serna and a copy of this report along with the appeal rights, LIC 9098 and LIC 811s were provided at the time of this visit. resident records which included Physician's Reports, North Tustin Health and Service Evaluation Results, and Admission Agreements. LPA Velazquez along with the Maintenance Director tested several doors throughout the facility that all meet ADA guidelines. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegation: Facility doors are a hazard is deemed UNSUBSTANTIATED. An exit interview was conducted with Business Office Director Leo Serna and a copy of this report along with the LIC 811s were provided at the time of this visit.