complaint·November 8, 2022

Insufficient staffing to meet resident needs This investigation included interviews with 5 residents, 3 facility licensee, facility administrator and direct care staff. LPA reviewed service hours and compared the level of care for residents. The facility does have a contract with a caregiver agency that will send over caregivers upon request to ensure the staffing level is met. Based on the information obtained, the allegation that there is Insufficient staffing to meet resident needs is deemed UNFOUNDED at this time, meaning, that the allegation was false, could not have happened and/or is without a reasonable basis. Facility doors are not secured or equipped with an auditory device or other alert feature to monitor exits LPA arrived at the facility unannounced to conclude the complaint visit for the above allegations. LPA met with Administrator Mary Bot. Over the course of the investigation, LPA reviewed facility documents, conducted interviews, obtained copies of facility documents, and inspected facility grounds. The facility is equipped with an Auditory System on the doors which are used to notify staff. This signal system in the facility does meet guidelines for Title 22. This agency has investigated the complaint alleging residents not given alarm devices. Based on LPA’s observation and records reviewed, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. To continue see 9099-C2 C-2 Staff do not ensure that residents are fed nutritious meals with a sufficient quantity It was alleged that facility staff failed to provide residents with nutritious meals. Staff and residents interviewed stated the food they receive was nutritious. LPA reviewed records, conducted interviews, and toured the facility in regard to the allegation. It was stated in interviews with 5 residents and 3 staff that fruits and vegetables are provided to residents "every day". LPA toured the facility and observed a large number of fruits and vegetables as well as eggs and dairy, and a large amount of fresh and frozen meat. LPA obtained the facility menu and observed that meals regularly include fruits and vegetables and appear to be nutritious and of the quality and in the quantity necessary to meet the needs of the residents. Based on information obtained, the allegation may have happened or is valid, however, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Administrator's designated substitute is not available to manage the facility in the Administrators absence. LPA interviewed staff members and reviewed documentation. Regarding the allegation that residents are not being properly supervised, and the substitute administrator is not available to manage the facility in the administrator’s absence all staff and residents interviewed expressed that they believe there is sufficient staff coverage. There are plans in place when staff call in sick to call extra staff or use a staffing agency if needed to stay fully staffed. Residents who require constant supervision are kept busy with in activities room in common areas. ADM2 stated never received any calls after hours or during hours when ADM2 was working. Regarding facility administrator, it was found that ADM2 has a current Administrator Certificate and has been acting as the main administrator until the parents (Licensees/Administrators) return from vacation. Based on LPA’s observation and records reviewed, the allegation is UNSUBSTANTIATED, meaning 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.