complaint·February 27, 2024

CONTINUED FROM FORM LIC9099-A Regarding the allegation that Licensee does not ensure facility is adequately staffed to meet residents’ needs, the following has been concluded: Based on interviews and records reviewed, there is a constant of one med tech and three caregivers present during the AM shift, one med tech and two caregivers during the PM shift and two caregivers during the overnight shift which appears to meet the staffing requirements present in Title 22 of the California Code of Regulations. Interviews with residents were inconclusive as to whether failures to meet the need of care and supervision for individual residents occurred as a result of insufficient staffing. Regarding the allegation that Staff do not assist resident with transfers in a timely manner, the following has been concluded: Based on records reviewed and interviews conducted, measures such as a task schedule focused on the needs of a specific resident to be transferred in and out of bed were stated to have been implemented during the month of February 2024. Additionally, LPA accompanied by administrator tested the response from staff to an activation of the call system which appeared satisfactory. However, interviews provided accounts of multiple instances during which staff is alleged to have refused to assist or delayed assistance in transferring a resident. As a result, both allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM LIC9099 Regarding the allegation that Staff do not ensure resident call buttons is accessible to the resident while in bed, the following has been concluded: During two separate visits to the facility, LPA observed that pull cords activating the call system to alert staff were missing in at least three distinct units occupied by six residents. In a total of four other units observed, the bedside pull cords were observed to be positioned out of reach from residents, either at the foot of the bed, or behind the bed's head beyond the full rails observed in use as postural support. As a result, the call system is found to be either inaccessible or non-operational for at least 8 of the 33 residents currently admitted. The allegation is therefore found to be Substantiated, meaning that the preponderance of evidence standard has been met. A corresponding violation is being cited per California Code of Regulations Title 22, Division 6 on the attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.