Complaint·September 10, 2024

This is an amended report. (continued from LIC9099) LPA conducted interviews with AD and Staff (S1). AD and S1 stated R1 passed away and that R1’s file is being maintained at the Administrative Office. LPA reviewed R1’s records electronically. LPA observed a Death Report for R1 dated 8/17/2024. LPA determined they would not be able to conduct interview with R1. Based on record review, LPA determined, R1's social security number was not listed on any of the documentation in R1's provided files. On 10/9/2024, LPA conducted interview with facility's Ombudsman (OM). OM stated that, while at the facility on 8/12/24 they requested to see R1's hospice records. OM stated that the records were not produced during their visit and they did not receive a follow-up contact. LPA conducted interview with AD. AD stated that they spoke to OM over the phone on 8/12/24 and stated the file should be at the facility. AD stated they did not follow up with staff or OM. On 10/11/2024, LPA Mason returned to the facility. LPA conducted interviews with AD, staff (S1, S2) and Hospice Provider (HP). AD stated the resident was unable to communicate the social security number to facility. Staff stated they don't oversee the completion of documentation like that. HP stated they have record of R1's social security number. Regarding the allegation of: Licensee is not ensuring that a separate, complete, and current record is maintained for resident in care, based on interviews conducted and records reviewed, LPA determined R1’s file does not include a social security number. Title 22 Regulations state: "87506(b) Each resident’s record shall contain at least the following information: (2) Social Security number." Regarding the allegation of: Staff do not respond to requests for communication regarding resident in care in a timely manner, based on interviews conducted, OM stated that while at the facility, they requested R1's hospice file and did not receive the file or any follow-up communication. AD stated they were able to recall OM's request. AD also stated they did not follow-up with staff or OM to ensure OM received the records requested. Title 22 Regulations state: "87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately." The preponderance of evidence standard has been met. The allegation of Licensee is not ensuring that a separate, complete, and current record is maintained for resident in care is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.