complaint·May 16, 2023

Allegation: Questionable death. The Department received and reviewed report of suspected dependent adult/elder abuse (SOC341). The SOC 341 indicated, R1 passed away suddenly after complainant was told by staff (S1), “R1 is going to tell on us, we have to do something.” Complaint notified Local Long Term Care Ombudsman (LTCO), Adult Protected Services (APS), and Local Police Department (PD). The Department requested and reviewed R1’s Certificate of Death. Certificate of Death indicated the cause of death for R1 was aortic valve stenosis and sequentially coronary artery disease. Interview statement received from R1’s RP indicated, R1 was not on hospice but was on Home Health Care for the past 5 months. R1 suffered from Diabetes, a heart murmur, and neuropathy. R1 took prescribed medication to treat ailments. On 11/26/2022, RP last saw and spoke to R1 and observed R1 eating a small amount of food at the time. Interview statement received from S1 indicated, S1 was the primary caregiver at the residence. S1 stated R1 has been at the residence for approximately 4 or 5 months. S1 indicated R1 suffered from minor health issues. “R1 did not suffer from any major health issues. R1 just had a lot of typical old people health issue.” On 12/02/2022, the Department requested for R1’s death report from Placer County Sheriff Coroner’s office for review. According to death report, R1 was found unresponsive by care home staff. Roseville Police Department (PD) arrived and pronounced R1 dead at 0856 hours due to obvious signs of death. R1’s responsible party (RP) arrived and stated R1 had no complaints regarding R1’s care at the facility. S1 checked on R1 at 0130 hours and was still breathing. Nothing suspicious was noticed on the scene. R1 was participating in home health care. R1 was last seen by her primary care physician (PCP) three to four months ago. The Department received and reviewed police report from Roseville PD. Roseville PD investigated and gathered interview statement from complainant. According to police report, complainant did not disclose how S1 was responsible and did not witness S1 causing R1’s death, but suspects S1 had something to do with how S1 treats residents at the facility. Complainant stated a few days prior to R1’s death, R1 appeared to be in a more alert state. Complainant heard S1 say, “I hope she don’t make it or she is going to tell on me.” Referring to R1. Roseville PD will not be investigating the complaint reported due to no evidence to support the allegations. The Department received interview statement from the facility’s administrator. Administrator indicated she did not suspect anything suspicious about the death of R1. R1 was a 92-year-old resident who was in and out of hospice. On 12/02/2022, the Department received interview statement from an employee from APS. APS was present at the facility and observed the facility was clean, orderly, and did not observe anything suspicious during the visit. Allegation: Physical abuse. According to complainant, S1 is abusive towards the residents and is very rough when handling residents in care. Complainant stated, complainant observed S1 bend fingers, grab arms, and threw R5 on the bed. The Department requested and received R5’s physician’s report, admission agreement, and appraisal for review. According to admission agreement, the facility will assist with personal activities of daily living such as dressing, eating, toileting, bathing, grooming, and mobility tasks. Physician’s report indicated, R5 has Dementia and is unable to bathe self, dress, groom, and care for own toileting needs. The Department interviewed and received statements from a total of five (5) facility staff. S1 denied being physically abusive towards R5. Interview statement received from S2 indicated, S2 has not observed S1 being aggressive or being physically abusive towards residents in care. Interview statement received from S3 and S4 indicated, they have no observed any physical abuse at the facility. Interview statement received from Administrator indicated, she has not had any residents make a complaint about staff working at the facility. Administrator stated she has not observed any physical abuse at the facility. The Department received interview statement from R5’s responsible party (RP). RP indicated; RP has not witnessed any physical abuse at the facility. RP stated RP often visits R5 at the facility and if RP is not able to visit other family members are there on a daily basis. The Department interviewed and received statements from a total of two (2) residents (R6 and R7). Statements received from R6 and R7 indicated, they have not observed staff physically abusing residents in care. Allegation: Sexual abuse. According to complainant, S1 sexually assaults the residents because S1 makes inappropriate comments at work about sex and that some of the female residents had short pubic hair or shaved vaginas. Complainant indicated; complainant did not observe S1 sexually assault anyone. Complainant stated S1 often talked about going to strip clubs and would show videos of S1 at strip clubs. The Department conducted interviews with a total of five (5) facility staff. Interview statement received from S1 indicated, S1 have never acted inappropriately and denied sexually abusing residents in care. Interview statement received from S2 indicated, S2 has not observed S1 sexually abusing residents in care. The Department received interview statement from R5’s RP. RP stated there are no signs of sexual abuse with R5 or any other residents there. Interview statement received from S3 and S4 indicated, they have no observed any sexual abuse at the facility. The Department interviewed and received statements from a total of two (2) residents (R6 and R7). Statements received from R6 and R7 indicated, they have not observed staff sexually abusing or being inappropriate to residents in care. Allegation: Neglect/lack of supervision. The Department interviewed a total of five (5) staff. According to administrator, there are a total of five (5) caregivers working at the facility. A total of three (3) caregivers are scheduled to work the AM shift. There is an over night staff who provides care and supervision while residents in care are asleep. The facility has call buttons in all of residents’ bedrooms. Administrator explained there are only two (2) residents that uses the call button and the other three (3) residents don’t remember how to use them. Staff are with residents throughout their entire shift. Staff stays with residents in care in the common areas to ensure residents are not in their bedrooms all day. Interview statement received from S1 indicated, there are about three (3) residents who uses the call buttons. S1 explained that the facility is small so once the call button goes off staff knows that a resident needs assistance. There would be two (2) staff working, so one staff would stop his or her tasks and check on resident while the other staff continues the tasks he or she is working on. The response time is less than 30 seconds. The Department received interview statement from R5’s RP. RP stated there is no concern about the care and supervision the facility is providing for R5. RP stated the facility has gone above to care for R5 at the facility. In addition, the Department obtained and reviewed R1, R2, R3, R4 and R5’s physician’s report, needs and services, and appraisals. The Department was unable to determine whether the death of R1 was due to lack of care and supervision. The Department was unable to determine whether S1 sexually abused and physically abused R4 resulted of a lack of care and supervision. Due to the information above, CCL finds the allegations 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. An exit interview was conducted, and a copy of the report left at the facility.