Complaint·July 6, 2022

Fire Drill Training records indicated the facility conducted monthly Fire Drill Training on 01/30/2021, 02/11/2021, 03/31/2021, 04/30/2021,06/05/2021, and 06/26/2021. Maintenance Director, Jay Brown, conducted training on topics such as fire equipment functional, visual/audio devices checked, fire panel performed properly, follow-up corrective action- employee education/training, follow-up corrective action- disciplinary action, and head count of staff. Facility does not have records of Fire Drill Training from July 2021 through December 2021. Documents revealed that the facility has continued to conduct Fire Drill Training on 02/17/2022, 02/28/2022, and 06/29/2022. Interviews with a total of four (4) facility staff revealed that the facility's trainer went over facility's emergency disaster plan and conducted fire drills with staff. Allegation: Facility gates are locked to the residents. - Unsubstantiated. According to Complainant, facility has locked doors to prevent resident from using the courtyard. The Department interviewed a total of four (4) facility staff. Interview statements received from the four (4) facility staff indicated that doors used to go to the courtyard is locked. Residents would have to ask staff permission to use the courtyard for their safety. If a resident is out in the courtyard resident is able to enter the building at any time because the door is unlocked from the outside. On 7/6/2022, LPA and ED toured the courtyard together. LPA observed ED unlocked courtyard door with a key to go out into the courtyard, however, when going back into the the facility the door from the outside is unlocked. According to Complainant, the gates located at each sides of the building is locked to residents and staff which poses a threat to staff and residents incase of an emergency evacuation. LPA observed two different locks on both sides of the gates. One lock requires a key to open the gate. According to ED, the Fire Department is the only one that has the key to unlock and open the gate. ED stated she had a conversation with the Fire Marshall who indicated that if there was an emergency the Fire Department is able to get the facility on time to cut lock and get everyone out if necessary. The other lock is a combination code lock which requires someone to enter numbers to unlock gate. According to staff and ED, staff has the numbers to unlock the gate. Allegation: Staff do not properly maintain the kitchen. - Unfounded. On 2/15/2022, LPA Keosavang toured the interior and exterior of the facility together with ED. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, three (3) bathrooms, and kitchen. LPA observed kitchen area kept clean and free of litter, rodents, vermin and insects. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Soaps, detergents, cleaning compounds or similar substances stored in areas separate from food supplies This agency has investigated the complaint allegations listed above. The Department have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conduct and report provided to ED. Allegation: Residents rooms have not been properly maintained while in care. - Unsubstantiated. According to ED, Care staff are maintaining residents' bedrooms on a daily basis. Care staff's responsibility is to rinse the sinks, take out trash, and put everything away. On 02/15/2022, LPA toured the facility together with ED and observed five (5) residents rooms. LPA observed all residents rooms to be properly maintained. Interview statement received from care staff (S2) indicated, when regular care staff is not working at the facility because it's their days off and agency staff is covering, resident's rooms is unkempt. LPA finds the allegation to be UNSUBSTANTIATED , meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. Exit interview conducted. Copy of report provided.